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REHABILITATION HOSPITAL OF HENRY
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to ensure the administration of a topical analgesic was documented in accordance with approved policy for one Patient (P) (P#1) of three patients reviewed for rehabilitation therapy. This failure had the likelihood to result in the unsafe administration of a topical analgesic.
Findings included:
Review of a facility policy titled "Topical Analgesic Medication Use in Therapy," effective 10/07/2021, indicated, "Administration of topical analgesic medication must be documented by the treating therapist on the Patient's MAR [medication administration record], including time of administration and effectiveness."
P#1 physician's order, dated 09/25/2024 at 3:21 PM, directed therapy staff to apply menthol topical (Biofreeze Professional 5% topical gel, a pain-relieving gel) four times daily as needed to facilitate therapy.
"Progress Note-Physician" documentation, dated 09/26/2024 at 11:36 PM, revealed P#1 was seen while the patient was in the therapy gym that morning, and the patient verbalized shoulder soreness. Per the documentation, a recommendation was made for P#1 to use Bio freeze.
An "IP [inpatient] PT [physical therapy] Daily Documentation," record, dated 09/26/2024 at 12:18 PM, revealed a therapist applied Biofreeze to P#1 following the therapy gym session to relieve the patient's shoulder pain.
On 01/07/2025 at 4:15 PM, the Director of Quality and Risk (DQR) stated Biofreeze was not on the MAR for P#1, noting she would ask the Director of Therapy Operations (DTO) about it.
On 01/07/2025 at 4:18 PM, the DTO stated Biofreeze use/administration would be documented on a patient's MAR. The DTO confirmed the Biofreeze order for P#1 indicated administration by therapy, which was how the order needed to read for therapy to be able to document on the MAR. The DTO stated the therapist who applied Biofreeze to P#1 on 09/26/2024 did not document the Biofreeze application on the patient's MAR.