F0658

D

Failure to Follow Professional Standards for Transdermal Patch Administration and Documentation

Dunn Loring, Virginia Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

Facility staff failed to ensure professional standards of quality in medication administration for one cognitively intact resident with multiple chronic conditions, including Parkinson's disease, atrial fibrillation/flutter, chronic heart failure, type 2 diabetes, and hypertension. Review of the closed electronic clinical record and the March and April 2025 Medication Administration Records (MARs) showed that medications were not administered as ordered by the physician. Specifically, the Rivastigmine 9.5 mg/24 hr transdermal patch, ordered to be applied at bedtime for dementia and removed per schedule, had unclear and inconsistent removal times documented. The March MAR showed an order start date of 3/15/2025 and discontinue date of 3/27/2025, with entries to remove the patch at both 1:18 p.m. and 7:59 p.m., and to apply the patch at 8:00 p.m. The April MAR similarly listed two removal times, 2:33 p.m. and 7:59 p.m., with application at 8:00 p.m.

The MARs also lacked documentation of the anatomical sites where the Rivastigmine patches were applied, despite the DON acknowledging that documenting patch sites was important so staff would know where patches had been placed. During medication pass observations, interviewed LPNs stated it was important for nurses to administer medications and follow physician orders, yet the MAR documentation did not clearly reflect adherence to those orders or to professional standards for transdermal patch use. Reference materials cited in the report, including Lippincott Nursing Procedures and external guidance on transdermal patches, emphasized the need to follow physician orders, facility policies, and proper documentation, as well as the importance of rotating patch sites, underscoring the deficiencies identified in the resident’s medication administration records.