Medication Order Lacked Dosage for Topical Pain Reliever
Penalty
Summary
A deficiency was identified when a resident's physician order for Voltaren gel, a topical anti-inflammatory medication, lacked a specified dosage. The order instructed staff to apply the gel to the resident's knee and shoulder every 12 hours as needed for pain, but did not indicate the amount to be applied. This omission was noted in the resident's electronic medical record and confirmed during interviews with nursing staff, who acknowledged that all medication orders should include a dosage. The resident involved had multiple medical conditions, including edema, chronic kidney disease, congestive heart failure, muscle weakness, and pain, and required significant assistance with activities of daily living. The resident's care plan indicated that medications were to be administered as ordered and monitored for side effects or effectiveness. The facility's policy required that drugs be administered only upon written orders from authorized prescribers, with accurate implementation of those orders. The lack of a specified dosage in the Voltaren gel order constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs.