Failure to Administer and Document Topical Medication as Prescribed
Penalty
Summary
The facility failed to follow physician orders for a resident, identified as Resident R2, regarding the administration of a prescribed topical ointment. The facility's policy requires that medications be documented in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) after each administration. However, a review of Resident R2's records revealed that the prescribed Clobetasol Propionate ointment was not documented as administered according to the physician's orders. The orders specified that the ointment should be applied to various parts of the body twice daily for skin care and every 12 hours as needed for open areas. Interviews with Resident R2 indicated that the ointment had not been applied for several days, including the day of the interview. The Director of Nursing and the facility administrator confirmed the lack of documentation and administration of the ointment as per the physician's orders. The deficiency was identified through a review of the resident's clinical records, facility policies, and interviews with staff and residents.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. 1. R2's ointment was being administered and documented according to physician order. R2 had no adverse effects. 2. Initial audit of residents with ointments was completed to validate they are being administered and documented according to physician orders. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. Licensed nursing staff will be re educated on administering ointments and documenting according to physician orders. 4. DON/designee will complete random audits to validate administration and documentation of ointments according to physician orders for five times a week for four weeks and monthly for two months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.