Failure to Discontinue Medication After Change in Wound Care Orders
Penalty
Summary
A deficiency occurred when the facility failed to discontinue a medication order after a change in wound care orders for one resident. The resident, who had multiple diagnoses including dementia, CVA with left-sided hemiparesis, obesity, chronic pain, diabetes mellitus type II, and neuropathy, was initially prescribed Santyl ointment for sacral wound care. The physician's order for Santyl was replaced with a new wound care regimen that no longer included Santyl. Despite this change, the facility continued to administer Santyl ointment for thirteen documented instances after the new order was in effect. Observation confirmed that a licensed nurse applied Santyl to the resident's sacral wound area even after the medication was discontinued in the updated care plan. Interview with the Resident Care Manager confirmed that the Santyl should have been discontinued following the revised wound care order. This failure resulted in the resident receiving unnecessary medication administrations that were not aligned with the current physician's orders.