Incomplete Medication Administration Documentation in EMR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident who was prescribed levetiracetam for seizure management. The medication administration record (MAR) for this resident showed a code indicating 'other/see progress notes' for two consecutive days, but a review of the progress notes did not reveal any documentation clarifying whether the medication was administered as ordered. The facility's policy requires that each medication administration be documented, and any deviations or issues be recorded in the resident's medical record. Interviews with staff revealed that the LPN responsible for administering the medication on those days was unable to locate the medication initially and used the code to indicate this. However, after another nurse provided the medication from the emergency supply, the LPN administered it but failed to update the documentation or add a corresponding progress note in the electronic medical record (EMR). The DON confirmed that the LPN, who was new to the facility, was unsure how to properly document the administration after entering the initial code, resulting in incomplete and inaccurate medical records for the resident.