Failure to Follow Physician Orders and Secure Topical Medications
Penalty
Summary
The facility failed to ensure that services were provided in accordance with professional standards for three residents. One resident with cognitive communication deficit and metabolic encephalopathy had a physician’s order for a wanderguard bracelet to be placed on the left lower extremity, with staff to check its function and placement every shift. On multiple observations over several days, the resident’s wanderguard bracelet was seen lying on the overbed table while the resident ambulated in the room, often barefoot, and the resident stated he only had to wear the bracelet for seven days. Despite these observations, the February Treatment Administration Record documented that the wanderguard bracelet was in place every shift and that its function was checked nightly. Another resident, who required assistance with personal care and was legally blind, was observed on multiple occasions with a tube of Voltaren gel and a tube of wound treatment cream lying on the bedside stand within reach. During a medication pass with an LPN, these items remained accessible on the bedside stand. The roommate of this resident had diagnoses of dementia and delusional disorder and was care planned and observed to ambulate independently around the room. During a follow-up observation and interview with the Nursing Home Administrator and DON, the DON confirmed that the medication and cream should not have been left on the bedside stand.
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