Failure to Document Medication Administration in eMAR
Penalty
Summary
A deficiency occurred when the facility failed to ensure the accurate documentation of medication administration for a resident with multiple psychiatric diagnoses, including schizophrenia, anxiety disorder, major depressive disorder, and bipolar disorder. The resident, who had severely impaired cognition as indicated by a BIMS score of 7, had a physician's order for Haldol (Haloperidol lactate) injection to be administered intramuscularly as needed for schizophrenia. On the specified date, the ADON-LVN administered the Haldol injection following a new order due to the resident's aggressive behavior, as documented in the progress notes. However, the administration of the Haldol injection was not signed off in the resident's electronic medication administration record (eMAR) as required by facility policy, which states that the MAR should be signed after medication is administered. The ADON-LVN acknowledged forgetting to document the administration in the eMAR because she was in a hurry to return to a meeting after giving the injection. The DON confirmed that the eMAR did not reflect the administration of the medication, although a progress note indicated it had been given. This failure resulted in incomplete medication administration records for the resident.