Failure to Remove Old Transdermal Patch Before Applying New Patch Resulting in Hospitalization
Penalty
Summary
A deficiency occurred when staff failed to remove an existing transdermal Rivastigmine patch before applying a new one to a resident with a history of coronary artery disease, hypertension, Parkinson's disease, and bipolar disorder. The resident, who required extensive assistance with daily activities and had documented cognitive impairment, was found to have multiple Rivastigmine patches on his body over several days. Medication administration records and staff interviews revealed that staff did not consistently locate and remove the old patch prior to applying a new one, and in some instances, staff could not find the previous patch but proceeded to apply another without a thorough body check or proper documentation. The resident subsequently exhibited increased confusion, agitation, and physical instability, including falls and hyperventilation. Staff discovered two patches on the resident during an episode of acute confusion, and further review indicated that the resident had as many as three patches on at one time. The resident's condition deteriorated, leading to hospital admission for acute encephalopathy. Medical records and interviews confirmed that the resident's mental status improved after the excess patches were removed and the medication was discontinued. Staff interviews highlighted inconsistent practices in patch administration, including failure to check for existing patches, improper documentation, and lack of adherence to protocols such as dating and initialing patches. The facility did not have a specific policy for transdermal patch administration, and staff were unclear about the correct procedures, contributing to the medication error and subsequent adverse event.