Improper Disposal of Nitroglycerin Patch Found on Resident’s Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper disposal of a nitroglycerin transdermal patch in accordance with professional standards and facility policy. During observation in the dining area, a surveyor saw a resident seated in a wheelchair with an oval, paper-tape-like object stuck to the wheelchair wheel. On closer inspection, the object was identified as a nitroglycerin patch labeled with a date of 2/3. Review of the resident’s physician orders confirmed that this resident did not have an order for nitroglycerin. The resident’s diagnoses include dementia, major depressive disorder, and schizophrenia, and the most recent MDS indicated that a BIMS could not be completed because the resident was rarely or never understood. When interviewed, an RN stated that only one resident on the unit had an order for a nitroglycerin patch and that the ordered patch would have been removed the previous night. The RN described the facility’s expected disposal process for nitroglycerin patches as folding the patch in half so the medicated sides adhere together and then placing it in a sharps container or wrapping it in gloves, placing it in the resident’s trash, and immediately removing the trash. The RN acknowledged that the patch found on the wheelchair wheel had not been properly disposed of. The DON similarly stated that nitroglycerin patches should be folded on themselves and placed in a sharps container and agreed that the patch observed on the wheelchair wheel was not properly disposed of, indicating noncompliance with the facility’s medication disposal policy and accepted professional principles.
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