Medication Allergy and Transdermal Patch Administration Errors
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors, including administering a medication to a resident with a documented allergy and not properly managing transdermal patch therapy. One resident with multiple diagnoses, including ovarian cancer, dementia, anxiety, depression, diabetes, and dysphagia, was admitted with documented allergies to Trazodone and Meloxicam, with noted reactions such as increased depression, aggression, abdominal pain, and nausea. Her care plan and pre-admission history and physical both identified these allergies. Despite this, after a pharmacy recommendation suggested Trazodone as an alternative to Hydroxyzine for insomnia and anxiety, the physician agreed and ordered Trazodone 50 mg daily, which was started and administered on multiple occasions. Review of the resident’s Medication Administration Record showed that she received Trazodone, a medication to which she was allergic, on five separate dates before the allergy was recognized and the medication discontinued. A progress note later documented by an RN indicated awareness that the resident had an allergy to Trazodone, and the physician was notified and changed the order to Melatonin, discontinuing Trazodone. The DON confirmed that the resident had previously had an order for and was administered Trazodone despite the documented allergy. A second deficiency involved another resident with diagnoses including type 2 diabetes mellitus, ataxia, hyperlipidemia, facial weakness following cerebrovascular disease, anxiety, dysphagia, and cognitive communication deficit, who had intact cognition but was dependent for all mobility and hygiene needs. This resident had an order for a Rivastigmine 24-hour transdermal patch for dementia, with explicit instructions to change the patch daily, place it on different areas of the body, and remove the old patch before applying a new one. During observation of incontinence care and a bed bath, the resident was found to have two Rivastigmine patches on the left shoulder/chest area, one dated for the current day and one for the previous day. An LPN verified the presence of both patches and stated she had removed a patch earlier that morning when applying the new one, indicating the resident must have had three patches on at the same time. Manufacturer instructions and facility policy required removal of the previous day’s patch and administration of medications in accordance with orders, which was not followed in this case.
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