Incorrect Documentation of Topical Ointment Administration
Penalty
No penalty information released
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Summary
The facility failed to ensure that a resident's Treatment Administration Record (TAR) was documented in accordance with physician's orders. Specifically, a physician had ordered a topical ointment to be applied to the resident's right hip four times daily for pain. However, review of the Medication Administration Record (MAR) and TAR showed that three staff members documented 11 consecutive entries over a three-day period indicating the ointment was applied to both hips, rather than only the right hip as ordered. This inconsistency was identified during record review and confirmed by facility leadership, who verified that staff had selected the incorrect indication from the dropdown menu in the electronic medical record system.