Failure to Document Controlled Medication Administration in e-MAR
Penalty
Summary
The facility failed to ensure that the administration of Norco, a controlled pain medication, was properly documented in the electronic Medication Administration Record (e-MAR) for a resident. Specifically, the Controlled Medication Count Sheet indicated that Norco tablets were removed from inventory on several occasions, but these administrations were not recorded in the e-MAR. This discrepancy was confirmed during a review of both the count sheet and the e-MAR, as well as through an interview with a Licensed Vocational Nurse, who acknowledged that the e-MAR was not signed to reflect the removal and administration of the medication. The resident involved had a history of Alzheimer’s disease, cardiomegaly, difficulty walking, and a history of falls, and was under a physician’s order to receive Norco as needed for pain management. Facility policy required that all administrations of controlled medications be immediately documented with the date, time, amount administered, and the nurse’s signature. The failure to document these administrations in the e-MAR constituted a breach of this policy and created a risk of miscommunication among healthcare personnel regarding the resident’s medication administration.