Failure to Accurately Document PRN Controlled Substance Administration in eMAR
Penalty
Summary
The facility failed to maintain accurate and consistent documentation in the electronic medication administration record (eMAR) for a resident with a diagnosis of opioid dependence who had a physician's order for PRN Percocet for pain management. On two consecutive days, the eMAR did not reflect all administrations of Percocet, as two doses given around 10 PM each night were documented on the controlled substance declining sheet but not entered into the eMAR. The nurse responsible for administering these doses confirmed during an interview that he had provided the medication and signed it out on the controlled substance declining sheet, but failed to document the administration in the eMAR due to distractions. Further review of nursing progress notes revealed no documentation regarding the resident's need for PRN Percocet on the days in question. Both the Director of Nursing and the Administrator acknowledged that all controlled substances should be documented accurately and consistently in both the controlled substance declining sheet and the eMAR. The resident also confirmed receiving the medication at the times in question, corroborating the findings of incomplete documentation.