Failure to Accurately Document Medication Administration in eMAR
Penalty
Summary
The facility failed to maintain and accurately document the electronic Medication Administration Record (eMAR) for two residents, as required by professional standards and the facility's own policy. Review of the medical records policy indicated that staff are expected to record all care provided, including medication administration, and to document any adverse reactions or abnormalities. However, for two residents, there was no documented evidence in the eMAR that multiple prescribed medications and supplements were either administered or not administered on several specified dates and times. This included medications for insomnia, constipation, pain, mood disorders, anxiety, nutritional supplementation, and blood thinning. Interviews and record reviews confirmed that the required documentation was missing for these residents, and the Director of Nursing acknowledged that staff should have documented whether medications and supplements were given or not. The absence of documentation included missing signatures and lack of evidence for administration or omission of medications, contrary to facility policy and accepted standards for maintaining resident medical records.