Improper Documentation of Topical Medication Administration
Penalty
Summary
The facility failed to ensure that staff who applied lidocaine patches to residents documented the administration on the Treatment Administration Record (TAR) as required. Instead, another staff member, specifically an LPN, signed off on the administration of the lidocaine patches for two residents, despite not having performed the application themselves. Observations confirmed that a Certified Medication Aide (CMA) applied the patches to both residents, but the LPN documented the completion of the treatment on the TAR. Interviews with staff revealed that this practice had been ongoing, with the LPN routinely signing off treatments completed by the CMA if the CMA forgot to document them. Both residents involved had physician orders for lidocaine patches to be applied for pain management, as reflected in their clinical records and Minimum Data Set (MDS) assessments. Facility policy required that the individual who administered the medication document the administration and prohibited the documentation of false information. The Assistant Director of Nursing and Director of Nursing both confirmed that the expectation was for the person who completed the treatment to document it, and that it was an issue if a nurse signed for a treatment they did not perform.