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Based on record review and interview, 1 of 1 registered nurse (RN) (Personnel #7) did not record Patient #1's entire medication list in the electronic medical record on 2/7/14.

Findings included:

Patient #1 presented in the facility's ED (emergency department) the afternoon of 2/7/14 with chief complaints of chest pain and abdominal pain with accompanying symptoms of nausea and vomiting. Personnel #7 was the triage nurse. During assessment and interview, Personnel #7 noted in the "ER Registration Form" that Patient #1's current medications were "Crestor" and "Famera (cancer treatment medication)." Past health medical history included breast cancer. Personnel #7 did not enter "Famera" medication in Patient #1's electronic medical record.

In a phone interview on 7/16/14 at approximately 3:15 PM in the presence of Personnel #3, Personnel #7 confirmed the findings above. Personnel #7 was asked why she did not electronically enter the "Famera" medication. Personnel #7 replied "I honestly don't know."