Failure to Remove Old Transdermal Patch Before Applying New Patch
Penalty
Summary
Licensed nurses failed to follow physician orders for a resident who was prescribed a scopolamine transdermal patch to be applied every three days for secretion control. During observation, the resident was found to have two identical scopolamine patches in place—one near each ear—despite the physician's order and manufacturer instructions specifying that only one patch should be worn at any time. The patch near the right ear was dated two days prior, while the writing on the patch near the left ear was smudged and unreadable. Interviews with nursing staff confirmed that the resident was not supposed to have two patches applied simultaneously, and the Director of Nursing acknowledged that the physician's orders were not followed. Facility policy also required medications to be administered according to written physician orders. The failure to remove the old patch before applying a new one resulted in the resident wearing two patches at once, contrary to both medical orders and manufacturer guidelines.