Failure to Administer Ordered Topical Antibiotic as Prescribed
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident when prescribed topical Clindamycin Phos 1% gel was not given as ordered. Facility policy dated 3/6/26 required that medications be administered as prescribed in accordance with good nursing principles and practices. The resident, who had diagnoses including bipolar disorder, paranoid personality disorder, adjustment disorder, conduct disorder, and atopic neurodermatitis, was documented on an MDS dated 11/2/25 as alert, oriented, and independent with all ADLs. A physician order dated 3/23/26 directed staff to apply Clindamycin Phos 1% gel to the armpit and groin every day and evening shift. Review of the March 2026 MAR showed the medication was not administered on the evening shifts of 3/27, 3/28, and 3/29, with nurse progress notes stating they were awaiting pharmacy. However, observation on 3/30/26 at 3:30 p.m. showed the Clindamycin gel was available with a dispense date of 3/23/26 on the label, and the DON confirmed the facility failed to follow the physician’s order for this resident. This deficiency centers on the missed evening doses of the ordered topical antibiotic despite its documented availability in the facility during the period when staff charted that they were awaiting pharmacy, in contradiction to facility policy and the physician’s written order.
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