Failure to Follow Physician’s Order for Barrier Cream Application
Penalty
Summary
The facility failed to implement a physician’s order for a resident requiring skin protection. Facility policy on Medication Administration, last reviewed in September 2025, required that medications be administered as prescribed and in accordance with written prescriber orders. The resident had diagnoses including heart disease, was alert and oriented, and was identified on the Minimum Data Set as being at risk for pressure sores. The care plan documented risk for altered skin integrity related to impaired mobility, incontinence, and a history of moisture associated skin damage (MASD), and included an intervention for staff to administer medications as ordered by the physician. A physician’s order effective in late December 2025 directed staff to apply a preventative barrier cream to the resident’s buttocks twice daily. A skin assessment documented MASD to both buttocks. Facility documentation from early January 2026 showed that a nursing assistant took a cream from the treatment cart and applied a topical analgesic (capsaicin cream), intended for relief of muscle and joint pain, instead of the ordered preventative barrier cream to the resident’s buttocks. In a subsequent interview, the Director of Nursing confirmed that staff did not follow the physician’s order and applied the incorrect cream. This constituted a failure to administer medications in accordance with facility policy and the prescriber’s written orders, as cited under 28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.
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