Failure to Specify Dosage for Topical Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not including a specific dosage in the physician's order for Voltaren (diclofenac sodium) gel. The order, which directed staff to apply the gel to the resident's right hip every six hours as needed for pain, did not specify the amount to be applied. This omission was identified during a review of the resident's electronic medical record, which also documented diagnoses of chronic pain, cognitive communication deficit, contracture, and multiple sclerosis. The resident's care plan and pain assessments indicated ongoing pain management needs, and the resident was observed waiting for transportation to a doctor's appointment to have her pain medication refilled. Interviews with nursing staff and administrative personnel confirmed that all medications should have a dosage specified by the physician and an indication for administration. The facility's policy on unnecessary drugs requires that each medication have an adequate indication for use, including consistency with manufacturer recommendations and clinical guidelines. The lack of a specified dose for the Voltaren gel order was not in accordance with these requirements, leading to the identified deficiency.