Failure to Timely Document Medication Administration in eMAR
Penalty
Summary
The facility failed to ensure that staff documented the administration of medications immediately after they were given to a resident. Review of medication administration records for one resident with diagnoses including dementia with mood disturbance, hypertensive heart disease, and adjustment disorder with depressed mood, showed that a licensed practical nurse (LPN) often documented medication administration hours after the medications were scheduled and administered. Audit reports revealed that medications scheduled for specific times were administered and documented significantly later, with some evening medications scheduled for 6pm being documented as late as 9:51pm or 10:06pm. The resident was cognitively intact at the time of the deficiency, as indicated by a BIMS score of 15. Interviews with the LPN and another staff member confirmed that the expectation is for nurses to document medication administration in the electronic Medication Administration Record (eMAR) immediately after giving the medications. The LPN acknowledged that she sometimes delayed documentation, possibly waiting until the next medication pass to sign off in the eMAR. Facility policy also requires documentation in the MAR immediately after administration. This failure to document timely affected the resident reviewed for pharmaceutical services.