F0658

D

Inaccurate Documentation and Omission of Prescribed Topical Medication

Chicago, Illinois Survey Completed on 12-04-2025

Penalty

No penalty information released

Summary

The deficiency involves the failure to administer and accurately document a prescribed topical medication for a resident. The resident had multiple medical diagnoses, including hypertensive heart and chronic kidney disease with heart failure, chronic diastolic heart failure, asthma, and major depressive disorder. A physician’s order dated 09/18/2025 directed that Clotrimazole External Solution 1% be applied to all toenails of both feet twice daily for three months for onychomycosis. On 12/02/2025 at 9:13 a.m., a surveyor observed an LPN administer oral medications to the resident but did not observe the LPN administer any topical medications. Despite this, the surveyor observed the LPN document that medications, including the topical Clotrimazole, had been given.

Record review showed that the medication administration audit record for that date and time contained documentation by the LPN that the Clotrimazole External Solution 1% was administered. In a subsequent interview, the LPN stated that he did not administer the topical medication during the observed medication pass and acknowledged that he should not have documented the medication as given when it was not administered, stating that medications should not be documented if not given because it can cause a medication error. The DON also stated that medication should not be documented if it is not administered. Facility policy on medication administration required that drugs be administered in accordance with written physician orders, and the staff nurse job description required adherence to facility policies and nursing procedures, including preparing and administering medications as ordered and reviewing medication records for accuracy and completeness.