Failure to Administer Ordered Topical Medication and Inaccurate MAR Documentation
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including interstitial pulmonary disease, chronic respiratory failure, and neuropathy, did not receive an ordered topical pain-relieving medication (Biofreeze gel) to both knees as prescribed. The resident required assistance with activities of daily living and did not have the dexterity to self-apply the medication. Despite this, the LPN responsible for the resident did not apply the Biofreeze gel as ordered, instead leaving it on the resident's bedside table and assuming the resident could self-administer it. The LPN subsequently documented in the medication administration record (MAR) that the medication had been given, even though she neither applied it herself nor observed the resident applying it. The issue was identified when the resident and her daughter reported that the medication was not being applied as ordered. Upon interview, the LPN confirmed she had not administered the medication but had signed it off in the MAR. The facility's policy required staff to only sign the MAR after actually administering the medication. The DON confirmed that the resident was not capable of self-application and that the LPN's actions were not in accordance with facility policy.