Failure to Clarify Orders, Provide Treatments, and Complete Monitoring
Penalty
Summary
Facility staff failed to clarify a physician's order for a dermatologic cream for a resident diagnosed with Atopic Dermatitis, resulting in unclear instructions regarding the application site. During observations, the prescribed cream was not available on the treatment or medication carts, and staff were unable to locate it. The resident's skin was observed to be extremely dry and scaly, with ashen arms and a dry face, indicating the treatment was not administered as ordered. The lack of clarity in the order and failure to reorder the cream contributed to the resident not receiving the prescribed therapeutic treatment. Additionally, staff did not monitor a resident prescribed psychotropic medication for extrapyramidal side effects (EPS), despite a pharmacy recommendation to do so. There was no documentation of EPS monitoring in the medication administration records for several months. In another case, a pharmacist recommended specific laboratory monitoring for a resident on iron supplementation, which was accepted by the provider. However, the required iron-related labs (ferritin, TIBC, TSAT) were not ordered, and only a CBC, CMP, and lipid panel were completed. These failures demonstrate lapses in following through on medication regimen review recommendations and ensuring appropriate monitoring and treatment according to physician orders.