Failure to Accurately Document PRN Medication Administration in Medical Record
Penalty
Summary
A deficiency occurred when the facility failed to maintain complete and accurate medical records for a resident with end stage renal disease, dependence on dialysis, and constipation. The resident had not had a bowel movement in several days, and after being flagged on a daily report, a nurse contacted the resident's nurse practitioner, who verbally ordered a PRN dose of Bisacodyl suppository. The nurse reported administering the medication, and the resident subsequently had a bowel movement. However, the nurse did not enter the Bisacodyl order into the electronic medical record (eMAR), nor did he sign off on the administration of the medication in the eMAR. The facility's protocol required that any new medication order be entered into the resident's electronic record, which would then populate the eMAR for proper documentation and sign-off after administration. Because the order was not entered, the medication did not appear on the eMAR, and there was no electronic record of its administration. Interviews with staff confirmed that the medication was given, but the required documentation steps were not followed. The Director of Nursing acknowledged that the nurse had not inputted the order or signed off on the medication in the eMAR, as required by facility policy. The only documentation of the medication order and administration was found in the resident's change in condition report and bowel movement task report, not in the official medication administration record.