Failure to Document Medication Administration in eMAR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN 2) prepared and administered some of a resident's medications but did not sign the electronic Medication Administration Record (eMAR) to document the administration. On the day in question, LVN 2 assisted another nurse (LVN 1) with the 9 a.m. medication pass for a resident who had moderate cognitive impairment and multiple diagnoses, including diabetes mellitus. LVN 2 prepared prescription and over-the-counter medications, placed them in a medicine cup, and administered them to the resident. However, there was no documentation in the eMAR reflecting that LVN 2 had administered these medications. Facility policy and statements from the Director of Nursing confirmed that the standard practice requires the nurse who prepares and administers medications to document the administration in the eMAR at the time the medication is given. The failure to document the medication administration resulted in an inaccurate medication record for the resident. The facility's own policies specify that only the licensed or legally authorized personnel who prepare a medication may administer it and must record the administration on the resident's MAR.