Failure to Ensure Nurse Competency in EMR Use Delays Resident Treatment
Penalty
Summary
A deficiency occurred when a registered nurse failed to enter physician orders for pain medication and a STAT x-ray into the facility's electronic medical record (EMR) after a resident complained of left arm pain and swelling. The nurse stated they did not receive adequate training on the EMR system (Sigma) and therefore did not transcribe the orders, instead verbally notifying the oncoming LPN to have the supervisor enter the orders. As a result, there was no documented evidence that the ordered Tylenol or x-ray were provided, leading to a delay in treatment. The resident involved had a history of cerebrovascular accident with hemiplegia and dementia, and was noted to have mentally impaired cognition. The resident's condition worsened, with increased swelling of the left arm, elevated blood pressure, and altered mental status, eventually requiring transfer to the hospital where a left arm fracture was diagnosed. Review of facility records confirmed the absence of documentation for the physician's orders and administration of medication, as well as a lack of evidence that the nurse had completed EMR training per facility policy. Interviews with the nurse, facility educator, and DON revealed inconsistencies in the orientation and competency verification process for EMR use. The nurse reported insufficient training and lack of familiarity with required documentation procedures, while the educator and DON described a structured orientation and competency sign-off process. However, the staff development checklist for the nurse did not show documented evidence of EMR training, and the nurse stated they had not signed any checklist for Sigma training.