F0684

E

Failure to Administer and Document Ordered Topical Treatments and Wound Care

North Hollywood, California Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care according to physician orders and professional standards of practice for two residents. For one resident with depression, cirrhosis, heart failure, and COPD, the admission record showed the resident was readmitted in January 2026 and had moderately impaired cognition, with dependence on staff for personal hygiene, toileting hygiene, and lower body dressing. Physician orders included daily-shift topical Nystatin powder to abdominal folds for MASD starting 1/28/2026, and Mupirocin 2% ointment to both legs for cellulitis starting 1/29/2026.

Review of this resident’s February 2026 Treatment Administration Record (TAR) with an RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials in the TAR boxes for the ordered Mupirocin ointment treatments to the left and right legs, and no licensed staff initials for the ordered Nystatin powder to the abdominal folds. The RN stated there was no documented evidence that these treatments were administered as ordered on those dates and times and acknowledged that failure to administer the treatments as ordered had the potential to negatively affect the resident’s care and potentially cause wound deterioration, infection, or delay of wound healing.

For a second resident admitted with paraplegia, a stage 4 sacral pressure ulcer, and sacral osteomyelitis, the H&P indicated intact decision-making capacity, and the care plan for pressure ulcers directed staff to provide wound care per treatment orders. Physician orders dated 1/23/2026 specified a multi-step daily-shift sacral/coccyx stage 4 pressure ulcer treatment, including cleansing with Dakin’s solution, application of a collagen dressing cut to wound shape, application of a hydrocolloid dressing, and coverage with abdominal pads and Mepilex foam. Review of this resident’s February 2026 TAR with the RN on 2/9/2026 showed that on 2/6/2026 and 2/7/2026 at the 7 a.m. administration time, there were no licensed staff initials documenting completion of the ordered sacral pressure ulcer treatment. The RN stated there was no documented evidence the treatment was done and that failure to administer the treatment as ordered had the potential to cause complications such as infection and deterioration of the pressure ulcer. The facility’s medication administration policy, revised 1/2026, stated that medications are to be administered safely, timely, and as prescribed, and that topical medications used in treatments are to be recorded on the TAR.