Failure to Administer Lidocaine Patches per Physician Order
Penalty
Summary
The facility failed to administer lidocaine 4% external pain patches according to the physician's order for one resident with diagnoses of right hip and low back pain. The physician's order specified that four lidocaine patches were to be applied daily to the resident's bilateral hips and bilateral lower back. However, review of the Medication Administration Record (MAR) and staff interviews revealed that nurses consistently failed to apply the prescribed number of patches. One nurse admitted to applying only two patches on the dates she worked, choosing either the hips or the lower back, and stated she did not seek clarification or a new order from the physician despite her belief that the resident no longer needed four patches. Another nurse reported only applying one patch on the dates she worked, acknowledging awareness of the order but unable to explain why she did not follow it, nor did she request clarification from the physician. The physician confirmed that the order was for four patches daily and stated that no staff had contacted him for clarification or to change the order. The Director of Nursing and Assistant Director of Nursing also confirmed that the nurses should have either followed the physician's order or sought clarification if there were questions. The failure to administer the medication as ordered was identified through observations, record reviews, and staff and physician interviews.