Unlicensed Staff Applied Prescription Topical Medications Without Nurse Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that prescription topical treatments were administered by a licensed nurse, as required by facility policy and professional standards. A cognitively intact resident with cerebral palsy, osteoarthritis, morbid obesity, a break in skin integrity, and risk for skin breakdown had physician orders for Triamcinolone Acetonide 0.1% cream to the shoulders and thighs twice daily for psoriasis, and Nystatin powder to the thighs and under the breasts twice daily for fungus. The resident’s care plan included treatments as ordered and weekly skin checks, as well as interventions for ADL self-care deficits and transfers with a mechanical lift and two-person assist. On observation, a CNA was seen performing ADL care and applying a cream from a four-ounce cup and powder to the resident’s under-breast area and bilateral thighs. The CNA was unsure where the prescription cream should be applied and relied on the resident’s directions, including application to the left armpit, which the resident identified as an area of psoriasis. The CNA questioned whether the area was psoriasis, stating it looked like a pimple. Shortly afterward, an LPN entered the room; the CNA asked if the left armpit area was psoriasis, and the LPN did not respond. The LPN measured and treated a new open area on the resident’s abdominal fold but did not assess the left armpit area. Interviews confirmed that the nurse had given the prescription Triamcinolone cream and Nystatin powder to the CNA to apply, that the CNA was unsure of the correct application sites, and that the LPN was uncertain whether CNAs should be applying prescription creams and powders and had not instructed the CNA on where to apply them. The DON confirmed that nurses should be applying prescription creams and powders and observing and charting on areas of concern, and that the LPN should have assessed the left armpit area. Facility policy stated that medications are to be administered by licensed nurses or other staff legally authorized to do so.
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