Failure to Document Insulin Administration in EMAR
Penalty
Summary
The facility failed to document the administration of Lantus (insulin) for one resident who was moderately cognitively impaired and had diagnoses including diabetes, hypertension, non-Alzheimer's dementia, anxiety, and depression. The resident had a physician's order for Lantus, 30 units, to be administered twice daily. Review of the electronic medication administration record (EMAR) for August and September showed missing documentation for several morning doses, with no indication that the resident was out of the building or that the medication was withheld for a documented reason. Interviews with nursing staff confirmed that all medications should be documented in the EMAR, and if not administered, a progress note should explain the omission. The facility's policy requires that medications be charted when given and that any refusals or omissions be documented. The lack of documentation for the specified dates and times was not explained by any changes in the medication order or resident absence, resulting in a deficiency related to pharmaceutical services and medication administration documentation.