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F0684
D

Failure to Administer Medication as Ordered by Physician

Philadelphia, Pennsylvania Survey Completed on 06-06-2025

Penalty

No penalty information released
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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

A deficiency occurred when a licensed nurse administered a lidocaine 4% patch to a resident's left shoulder during the morning medication pass, despite the physician's order specifying a lidocaine 5% patch. The nurse prepared and applied the 4% patch because only that strength was available in the medication cart and was unaware of where to obtain the correct 5% patch. Facility policy requires medications to be administered in accordance with prescriber orders, but this was not followed in this instance. The nurse confirmed the discrepancy during an interview, acknowledging the administration of the incorrect medication strength.

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