Failure to Follow Physician's Orders for Barrier Cream Application
Penalty
Summary
The facility failed to adhere to physician's orders for a resident, identified as Resident 2, regarding the application of barrier cream. According to the resident's care plan and physician's orders, the Triad barrier cream was to be applied every shift and after each episode of incontinence. However, interviews and clinical record reviews revealed that the cream was only applied every shift and not after each incontinent episode as required. This was confirmed by both the resident and a Licensed Practical Nurse (LPN), who acknowledged the deviation from the prescribed care plan. Further examination of Resident 2's clinical records showed multiple instances where there was no documented evidence of the cream being applied as ordered. Specific dates were noted where the application was missed on various shifts throughout March 2025. An interview with the Director of Nursing (DON) corroborated the findings that the barrier cream was not applied according to the physician's orders, leading to a deficiency in the quality of care provided to the resident.
Plan Of Correction
Resident #2 has had no adverse effects from moisture barrier not being documented. Current skin preventative creams and treatments will be reviewed with the physician or NP to determine necessary measures, and orders implemented as received. To identify residents who have the potential to be affected, the Director of nursing/ designee will complete a review of residents who are incontinent and receive moisture barrier to determine if any administrations missed. If missed administrations identified, a skin check will be conducted. To prevent recurrence, the licensed nursing staff will be educated on the physician/ provider orders policy including carrying out orders by the Director of nursing/ designee. To maintain and monitor compliance, audits of 5 residents receiving moisture barrier will be conducted by the Director of nursing/ designee to ensure residents receive it as ordered weekly x 4 weeks and monthly x 2.