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Based on review of records and interview with staff, the facility failed to ensure that drugs and biologicals were administered in accordance with the practitioner's orders for 1 of 1 patient whose record was reviewed. Patient #1 had a physician order for barrier cream to treat decubitus ulcers twice daily, but there is no documentation regarding application of the cream on 2 occasions.

Findings were:

Review of the medical record of Patient #1 revealed that on 3/11/12, the physician ordered a consult with the wound care team to treat the patient's stage 2 sacral decubitus ulcers. (A decubitus ulcer is a pressure sore or what is commonly called a "bed sore." A stage 2 ulcer is characterized by a blister either broken or unbroken.) Following a wound care assessment, orders were written 3/13/12 for wound care including cleansing the left and right buttocks with soap and water and applying Cloud Cream twice daily and as needed. Review of the medication administration records (MAR) indicate that 2 doses of Cloud Cream were missed; one at 9 am on 3/15/12 and another at 9 pm on 3/18/12. There was no documentation by the nurse indicating why the doses were not given.

An in-person interview was conducted with Staff #2, the facility Quality Management Director, the morning of 6/19/12. Staff #2 acknowledged the finding and stated that nurses are supposed to circle a missed dose on the MAR and document the reason for holding the dose. This documentation was not found in the record, nor were the dosage times circled on the MAR.