Incomplete EMAR Documentation for Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records related to insulin administration for one resident. The resident had diabetes, as documented on an admission MDS dated 01/02/2026, and had a physician’s order for Lantus, a long-acting insulin, to be given as 10 units every morning between 8:00 A.M. and 10:00 A.M. and at bedtime between 8:00 P.M. and 10:00 P.M., starting 01/15/2026. Review of the resident’s February and March 2026 EMARs showed multiple blank spaces where administration of the ordered Lantus doses should have been documented. Specifically, there was no documentation of the bedtime dose on 02/01, 02/04, 02/08, 02/11, 02/15, 02/16, 03/03, 03/13, and 03/22, and no documentation of the morning dose on 02/26. During an interview, RN 8 stated there should not be blanks on the EMAR and that when medications are administered, they should be documented as given, and if not administered, the nurse should document that the medication was not given and the reason why. Review of the resident’s progress notes showed no entries explaining or addressing the missing documentation for these insulin doses. The facility’s Medication Administration policy, dated February 2017, required staff to circle initials on the MAR if a medication is not administered as ordered and to record the reason in the PRN/Omission Medication section of the MAR. The lack of documentation on the EMAR and in the progress notes for the ordered Lantus doses was not consistent with this policy and resulted in incomplete and inaccurate medical records for the resident.
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