Failure to Administer Ordered Topical Medication for Skin Rash
Penalty
Summary
A deficiency occurred when nursing staff failed to administer Diphenhydramine HCl Cream 2% as ordered by a physician for a resident with a documented skin rash. The resident, who was admitted with multiple diagnoses including pneumonia, acute respiratory failure with hypoxia, and hemiplegia, was noted to have a rash on the right arm, left chest, and left leg. The physician ordered the topical medication to be applied every eight hours as needed for the rash, but review of the Medication Administration Record (MAR) showed that the medication was not administered for a period of ten days. Interviews with the resident and the treatment nurse confirmed that the cream was not applied during this time, and the nurse acknowledged that the medication should have been given as ordered. The resident's cognitive skills were moderately impaired, and they were dependent on staff for personal care. During the period when the medication was not administered, the resident continued to have rashes, as observed by the treatment nurse. The facility's policy required medications to be administered and documented per physician orders, but this was not followed in this case. The Director of Nursing confirmed that the medication was not given as ordered and acknowledged the importance of following physician instructions for medication administration.