Unnecessary Nicotine Therapy While Resident Continued to Smoke
Penalty
Summary
The facility failed to ensure a resident’s medication regimen was free from unnecessary medications when a resident received nicotine replacement therapy while also smoking cigarettes. The resident, who had multiple diagnoses including incomplete quadriplegia and COPD, was admitted with orders for a 14 mg/24 hr nicotine transdermal patch to be applied daily and nicotine polacrilex gum 4 mg to be given every 3 hours as needed for nicotine craving. The electronic health record documented that the resident was assessed for independence with smoking on two occasions, and the MAR showed that the nicotine patch was administered as ordered. The DON stated the resident was an infrequent smoker but acknowledged the facility could not provide documentation that the resident smoked infrequently while still using the nicotine patches and having an active order for nicotine gum. This resulted in the resident simultaneously having and using nicotine patches, having an order for nicotine gum, and continuing to smoke cigarettes, which the surveyors determined did not meet the requirement that each resident’s drug regimen be free from unnecessary drugs and placed the resident at risk for adverse outcomes from overmedication.
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