Failure to Discontinue Unnecessary Antibiotic Ointment
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of an antibiotic ointment. The facility's policy requires a thorough evaluation of each resident's drug regimen to promote positive outcomes and minimize risks. However, for one resident with cerebral palsy, chronic respiratory failure, a tracheostomy, and ventilator dependence, there was an ongoing order for triple antibiotic ointment to be applied to the tracheostomy stoma site. This order was in place from September 24, 2024, without any documented clinical assessment or evidence of skin damage that would necessitate its use. The facility's consultant pharmacist reviewed the resident's medication regimen multiple times between October and December 2024 but did not identify the lack of clinical documentation supporting the use of the antibiotic ointment. During an interview, the Director of Nursing confirmed the absence of documentation for skin damage and acknowledged that the ongoing use of the ointment should have been identified and addressed earlier. The resident's physician eventually assessed the tracheostomy site and discontinued the ointment after finding no skin damage.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R9. 2) The Facility reviewed R9, and had a new skin assessment completed, site has been healed and treatment d/cd. 3) All current residents were reviewed for correct skin assessments and orders relating to those skin assessments. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accurate skin assessments and treatment orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. 3) Education will be provided to consultant pharmacist re: reviewing all medications to include ointments and treatment medications and Pharmacy Recommendations will be reviewed to ensure that ointments and treatment medications are reviewed by the Pharmacist. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with treatments for skin assessments then five (5) random residents 1x week for 2 months. 2) The Director of Nursing or her designee will conduct random audits for ointments and treatment medications to compare Physician orders against Pharmacy Reviews and will review 5 random residents pharmacy recommendations monthly for compliance with treatments for skin assessments and pharmacy recommendations, then five (5) random residents for 2 months. Pharmacy recommendations are received monthly. 3) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.