Failure to Verify and Accurately Document Fentanyl Patch Placement Each Shift
Penalty
Summary
The deficiency involves the facility’s failure to verify and accurately document the placement of a prescribed narcotic pain patch as ordered for one resident. The resident was admitted with multiple diagnoses including chronic and unspecified pain and had a physician’s order for a Fentanyl 25 mcg/hour transdermal patch to be applied every 72 hours with rotation of the site. The Medication Administration Record (MAR) also contained an order for Fentanyl patch placement checks every shift, with documentation required on the MAR. On the date in question, the MAR showed that both day and night shift placement checks were documented as completed. However, the facility’s incident report documented that during the night shift placement check, the Fentanyl patch was found to be missing, despite earlier documentation indicating it was in place. Interviews with nursing staff revealed inconsistent practices and a failure to follow the facility’s policy and the physician’s order for verification of patch placement. One LPN stated that Fentanyl patches are checked every shift with the outgoing nurse present, and that the patch’s presence, date, and initials are documented on the MAR. Another RN reported that the nurse on duty checks the patch alone, without the outgoing nurse. A different LPN acknowledged that on the morning in question she intended to verify the patch but became distracted by other residents and events in the hallway, did not actually see the patch, yet documented on the MAR that it was in place; she later discovered with another LPN at the end of her shift that the patch was missing and stated she should have documented “No” for patch placement. The DON confirmed that both oncoming and outgoing nurses are supposed to check patch placement together each shift, and the facility’s narcotic pain patch policy requires verification of the patch site and date every shift with documentation in the MAR, which did not occur as required for this resident.
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