Failure to Ensure Immediate and Accurate Medication Documentation
Summary
Staff were required to follow the administration process of pouring, passing, and immediately signing the EMAR for safe and accurate documentation of medication administration. When questioned about the acceptability of advance documentation in the EHR for care and services, including medication administration, the DON confirmed that such practice was not acceptable. The DON also acknowledged that any missed medication could significantly impact a resident's health, depending on the medication's indication. During an interview, both the Administrator and DON were informed of and acknowledged these findings.
Penalty
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