Failure to Administer Correct Topical Treatment and Prevent Recurrent Injuries
Penalty
Summary
The facility failed to ensure that a resident received the correct topical treatment as ordered by a physician. One long-term resident in the dementia care unit reported using a cream for an itchy back, and a tube of Dimethicone skin protectant was observed at the bedside. However, a review of the resident's physician orders did not reveal an order for Dimethicone, and the Assistant Director of Nursing confirmed that a different cream had been ordered for the resident. This indicates that the resident was using a topical product not prescribed by the physician, contrary to facility policy and physician orders. Additionally, the facility failed to protect another resident from injury related to multiple episodes of bruising. This resident, also with dementia, was noted to have bruising on several occasions, as documented in treatment administration notes. Despite these findings, subsequent skin assessments did not consistently document the presence of bruising. The resident was found to have significant bruises on both feet on separate occasions, with injury investigation reports attributing the injuries to contact with a tray table and noting the resident's use of anticoagulant medication, which increased the risk of bruising. Although the injury investigation reports recommended interventions such as applying protective footwear and keeping the area around the resident's feet clear, there was no evidence in the physician orders that these interventions were implemented. The Assistant Director of Nursing and Director of Nursing both confirmed that these interventions should have been ordered and documented, but this was not done, resulting in a failure to implement measures to prevent further injury.