Failure to Transcribe and Administer Physician-Ordered Rash Treatment
Penalty
Summary
A deficiency occurred when a physician's order for triamcinolone acetonide 0.1% cream, prescribed by a nurse practitioner for a resident with an all-over body rash/contact dermatitis, was not transcribed into the electronic medical record (EMR). The resident, who had diagnoses including major depressive disorder, COPD, and anemia, was cognitively intact and reported ongoing discomfort and itching from the rash. Despite the order being documented in the nurse practitioner's progress note, it was not entered into the current physician orders, resulting in the treatment not being administered. Observations confirmed the presence of a scattered, red rash on the resident's upper and lower extremities and back. The resident reported that staff applied lotion only to her legs and not to other affected areas, and that no treatment had been applied to the rash. Interviews with an LPN and the DON verified that the order for the cream was not transcribed and no treatments were documented or administered for the rash, contrary to facility policy requiring maintenance of physician orders and progress notes.