Failure to Timely Document Medication Administration on eMAR
Penalty
Summary
The facility failed to ensure that staff documented medication administration on the electronic Medication Administration Record (eMAR) in a timely manner for one resident. According to facility policy, the individual administering medication must initial the resident's MAR immediately after giving each medication and before administering the next. During an observed medication pass, a nurse administered several scheduled medications to a resident but did not document the administration on the eMAR at the time the medications were given. The nurse later confirmed in an interview that she had not documented the administration because she was in a hurry to move to the next resident. Audit reports showed that the documentation was entered nearly three hours after the medications were actually administered. The resident involved had a history of essential primary hypertension, type 2 diabetes mellitus, bilateral primary osteoarthritis of the knee, and adult failure to thrive, and was assessed as having moderate cognitive impairment. The resident's care plan included interventions for medication administration and monitoring for side effects. Multiple staff interviews, including with the ADON, DON, and Administrator, confirmed that the expectation was for medication administration to be documented immediately after giving the medication, and that delayed documentation was not consistent with good practice or facility policy.