F0842

E

Incomplete MAR/TAR Entries and Unsigned Progress Notes for Two Residents

Costa Mesa, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The facility failed to maintain complete and accurate medical records in accordance with its own charting and documentation policies. For one resident who lacked decision-making capacity, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January and February showed multiple instances where ordered medications and treatments were not signed as administered. These included laxatives (polyethylene glycol and sennosides), a protein supplement (Pro-Stat), famotidine for GERD, Sinemet for Parkinson’s disease, chlorhexidine mouthwash, ammonium lactate lotion, and G-tube site care on numerous specific dates and times. Facility policy required the individual administering medications to initial the MAR after giving each medication and before administering the next, and required that all services, medications, and treatments be documented completely and accurately in the medical record.

For another resident, also documented as lacking capacity to understand and make decisions, review of the closed medical record showed that multiple progress notes over several months were left in draft status and not signed. Specifically, six health status notes and one IDT note were incomplete, as indicated by the “view draft” status in the electronic record. During interviews and concurrent record reviews, the DON confirmed the gaps and incomplete documentation in the MAR and TAR for the first resident and verified that the second resident’s progress notes were not signed and therefore incomplete, acknowledging that the medical record remained open to alteration because the notes were not finalized. These findings demonstrated that the facility did not ensure complete documentation of medications, treatments, and progress notes as required by its policies.