Failure to Administer and Document Medications and Wound Treatments as Ordered
Penalty
Summary
The facility failed to administer medications and treatments according to physician orders, resident preferences, and facility policy for one resident. The resident was admitted with diagnoses including presence of a right artificial knee joint and cervical radiculopathy. Facility policy on administering medications required that medications be given safely, timely, and as prescribed, with the right medication, dose, time, and method, and that all administrations, holds, refusals, or time changes be documented in the electronic health record, with notification to the responsible party and attending physician as applicable. Review of the medication audit for this resident showed that Naproxen 500 mg, ordered twice daily with meals for arthritis pain and scheduled for 8:00 a.m., was administered at 9:23 a.m. Lidocaine 4% patch ordered once daily to the right lower extremity for pain and scheduled for 9:00 a.m. was documented as administered at 3:36 p.m. Diclofenac 1% topical gel ordered four times daily to the right leg for pain, with a scheduled 9:00 a.m. dose, was documented as given at 3:34 p.m., and the 12:00 p.m. dose was also documented as administered at 3:34 p.m. Celecoxib 200 mg ordered once daily for pain and scheduled for 9:00 a.m. was administered at 3:35 p.m. The Regional Nurse confirmed that these medications were administered late. The facility also failed to provide and document ordered wound care treatments for the same resident’s right knee following total knee replacement. The treatment administration record for January showed a physician order to remove the Mepilex dressing on the right knee on a specified date and leave the area open to air one time only for one day; there was no documented evidence that this treatment was completed on that date. Another order directed staff to cleanse the right knee incision with normal saline, pat dry, and cover with a bordered gauze dressing daily and as needed for soiling, with saline solution listed as to be applied topically every four hours as needed for wound care; there was no documented evidence that this treatment was completed on the specified date. These findings were cited under 28 Pa. Code 211.10(c) resident care policies and 28 Pa. Code 211.12(d)(1) nursing services.
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