Failure to Document Medication Administration in EMAR
Penalty
Summary
The facility failed to ensure accurate and complete medical records for four residents when medication administration during the evening shift was missing from their Electronic Medication Administration Record (EMAR). Specifically, a licensed nurse did not document the administration of multiple scheduled medications, including anticonvulsants, cholesterol-lowering agents, laxatives, pain medications, antianxiety medications, antidepressants, sleep aids, and muscle relaxants for residents with conditions such as seizure disorder, hyperlipidemia, constipation, diabetes, anxiety, depression, neuropathy, and pain. The absence of documentation was identified during a review of the EMARs, which showed that the nurse did not sign for the administration of these medications on the specified date. Interviews with staff revealed that the nurse responsible for medication administration experienced issues accessing the EMAR due to a password problem, but was still able to view the medication list and administer medications with assistance from another nurse. However, the nurse did not document the administration in the EMAR at the time. Additional staff interviews indicated that sharing credentials to access the EMAR was not permitted, and facility policy required licensed nurses to chart each medication administered, including the time and their initials, on the MAR.