Failure to Follow Physician's Order for Pain Management Patch Placement
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow a physician's order regarding pain management for a resident with significant medical needs. The resident, who had been admitted with a displaced intertrochanteric fracture of the right femur and an unspecified fracture of the sacrum, also had severe cognitive impairment and required staff assistance for activities of daily living. The physician's order specified that a lidocaine patch was to be applied topically to the resident's right hip in the morning for pain management and removed per schedule. During a surveyor's observation, it was found that the lidocaine patch had been applied to the resident's right thigh instead of the right hip as ordered. The LPN confirmed the incorrect placement when asked to review the order in the presence of the Unit Manager and surveyor. The facility's medication administration policy required medications to be administered according to prescribed orders, including verifying the correct method and site of administration. The Director of Nursing confirmed that the LPN should have followed the physician's order for the correct application site.