Failure to Administer Ordered Nicotine Patch Due to Unavailability and Lack of Physician Notification
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to administer a nicotine transdermal patch as ordered for a resident with diagnoses including spinal stenosis, depression, and anxiety disorder. The physician's order specified daily application of a 21 mg nicotine patch due to tobacco use, starting on 02/06/25. Medical record review showed that on three consecutive days, the patch was not administered because it was not available, as documented in the progress notes. There was no documentation that the physician was notified about the unavailability of the medication, and the DON confirmed that she was not informed of the issue. The same nurse was responsible for medication administration on all three occasions but could not recall the events when questioned.