Incomplete Documentation of Daily Wound Treatment on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident receiving a prescribed wound treatment. A male resident with diabetes, muscle weakness, lack of coordination, urinary retention, and pain was identified as cognitively intact and at risk for pressure ulcer/injury. His physician’s order and MAR directed that TRIAD be applied to his buttocks once daily for wound healing, with no end date. However, review of the Treatment Administration Record (TAR) showed missing documentation for this TRIAD treatment on multiple dates (3/1/25, 3/6/26, 3/7/26, 3/11/26, 3/13/26, 3/14/26, 3/15/26, and 3/16/26). The resident’s care plan documented risk for altered skin integrity related to impaired mobility, with interventions to reduce friction, but the corresponding daily treatment documentation was incomplete. During interviews, the resident reported he had complained about staff not administering some medications, acknowledged he often refused medications, but stated he had been receiving a cream treatment to his buttocks every morning and did not want the area to worsen. The ADON confirmed the expectation that staff document all medications and treatments on the MAR/TAR, including refusals, and stated there should be no blanks because they could be interpreted as missed medications or treatments. The ADON and DON both stated that in this resident’s case, he frequently refused medications but did not refuse the TRIAD treatment. Nursing staff, including an LVN, stated that floor nurses were responsible for wound care treatments and that any treatment not done as ordered, or refused, should be documented at the time, with no blank spaces on the MAR/TAR. Facility policy on documentation required complete, accurate, timely, and properly signed clinical record entries, including on medication sheets, but the missing TAR entries for the TRIAD treatment showed this standard was not met for the resident.
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