Inaccurate Documentation in eMAR for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation in the electronic Medication Administration Record (eMAR) for two residents. For one resident with a history of unhealed pressure ulcers and who was cognitively intact, the eMAR and wound care assessment indicated that a wound care nurse evaluated and treated the resident's wounds on a specific date. However, both the resident and the nurse confirmed that no such evaluation or treatment occurred on that date, and the nurse could not explain why the documentation was inaccurate. Facility leadership, including the Director of Nursing and a corporate nurse, confirmed the documentation was incorrect and should not have been entered as such. For another resident who was admitted to a hospital and later returned to the facility, the eMAR showed that multiple medications and care tasks were documented as completed during the resident's absence from the facility. These included administration of eye drops, tube feedings, repositioning, and other nursing interventions, all recorded as performed by specific LPNs. Interviews with staff confirmed that medications and tasks should only be documented if actually performed, and the Director of Nursing acknowledged that the eMARs should have been accurate and not indicated completion of tasks that did not occur.