Failure to Administer Clonidine Patch Leads to Hospitalization
Penalty
Summary
The facility failed to adhere to a physician's order for a resident, resulting in a significant health event. The resident, who was admitted with diagnoses including unspecified dementia, hypertension, and renal insufficiency, was prescribed a weekly Clonidine patch to manage their blood pressure. However, the medication administration record (MAR) showed that the patch was not applied as scheduled on several occasions, with no documented reason for the omission on December 6th. This oversight led to the resident experiencing elevated blood pressure and other symptoms, necessitating hospitalization. Upon review, it was discovered that the resident had not received the Clonidine patch for several weeks, leading to Clonidine withdrawal and uncontrolled hypertension. The resident was sent to the emergency room with symptoms including elevated blood pressure, increased pulse, and vomiting. The hospital staff identified the presence of an old Clonidine patch dated from a previous month, indicating a lapse in medication administration. Additionally, the resident was mistakenly given Hydralazine, to which they were allergic, further complicating their condition. Interviews with the resident's family and facility staff confirmed the failure to follow the physician's order for the Clonidine patch. The family was informed of the resident's condition and the medication error after the resident was already hospitalized. The facility's administration acknowledged the oversight and the failure to identify the issue until alerted by the hospital, highlighting a significant lapse in the facility's medication administration and monitoring processes.
Plan Of Correction
Initial audit was performed by DON/ADONs of all medication patches. Initial education was provided to all licensed staff on policy N-M-05 Medication Administration General Guidelines and N-M-115 Medication Administration Transdermal. All licensed nursing staff will be educated on N-M-05 Medication Administration General Guidelines, N-M-115 Medication Administration Transdermal and N-M-150 Medication Error Reporting, Analysis and Correction (MERF). DON/ADON/Designee to audit medication patches weekly x4 and bi-weekly x2. Results of audit will be reviewed and evaluated at QAPI meeting.