Untimely Medication Administration and Delayed eMAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to administer prescribed medications in a timely manner according to physician orders and to document administration promptly on the electronic medication administration record (eMAR). On the date of survey, multiple nurses on different floors reported starting their shifts around 7:00–7:30 AM and beginning medication passes between 7:30–8:00 AM, yet by approximately 10:11–10:39 AM several had not completed their medication passes. When the surveyor reviewed the eMARs with these nurses, multiple residents’ medication entries appeared in red, which the nurses stated indicated that the medications were late. Some nurses also stated that they had administered certain medications but had not yet documented them on the eMAR. One nurse assigned to the third floor stated she had completed her medication pass and acknowledged that medications not given on time are considered medication errors and that all medications should be given on time according to physician orders. The Director of Nursing stated that the facility’s time frame for medication administration is one hour before and one hour after the scheduled time. Facility medication administration audit reports for the same date documented that multiple residents on the second, third, fourth, and fifth floors received their medications late. The facility census documented 34 residents on the second floor, 57 on the fourth floor, and 54 on the fifth floor, indicating that the issue had the potential to affect 145 residents. Facility policy titled “Medication Pass,” dated 07/02/2025, states in part that after medication is administered to each resident, staff must sign the MAR to indicate it was given. The observations, staff interviews, and audit reports collectively show that medications were not consistently administered within the prescribed time frame and were not consistently documented immediately after administration, resulting in untimely medication administration for multiple residents.
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