Failure to Accurately Document Topical Antibiotic on TAR
Penalty
Summary
The facility failed to ensure medications were accurately documented on the Treatment Administration Record (TAR) in accordance with its medication administration policy. The policy required staff to document each medication as it was prepared on the MAR/TAR and to document a reason if a medication was not given as ordered. For one resident with intact cognition, admitted with diagnoses including depression, stage 4 sacral pressure ulcer, paraplegia, presence of urogenital implants, neuromuscular dysfunction of the bladder, and an indwelling urinary catheter, a nurse practitioner ordered Clindamycin 1% topical ointment to be applied to a penile erosion site twice daily for 14 days. The corresponding physician order specified Clindamycin Phosphate External Solution 1% topical, to be applied to the penile erosion site twice daily for infection over the same 14-day period. Review of the resident’s January–February 2026 TAR showed missing documentation for the 6:00 p.m. dose of the Clindamycin topical medication on multiple dates within the treatment period, with no entries indicating administration or reasons for omission. During interview, the DON confirmed there was no documentation on the identified dates and acknowledged that nurses should have documented on the TAR after administering the topical medication. In a separate interview, an LPN stated she remembered the Clindamycin 1% topical order and confirmed she did not document on the TAR after administering the ointment, despite being required to do so.
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