Failure to Administer Prescribed Topical Medication as Ordered
Penalty
Summary
The facility failed to follow the care plan for a resident who was admitted with multiple diagnoses, including acute on chronic diastolic heart failure, urinary tract infection, chronic kidney disease, unspecified dementia, cerebral ischemia, and essential hypertension. The resident was assessed as severely cognitively impaired, with a BIMS score of 05. According to the physician's order, the resident was to receive Lotrisone cream twice daily for seven days. Review of the Medication Administration Record and Treatment Administration Record for the specified month revealed that four doses of the prescribed Lotrisone cream were not administered as ordered, with no documentation indicating the doses were given on the specified dates. The Director of Nursing confirmed that these doses were missed after reviewing the resident's records.