Double Application of Lidocaine Patch Contrary to Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer medication according to a physician’s order when a resident received two Lidocaine (Lidoderm) patches instead of the prescribed single patch. The resident was an adult male with multiple diagnoses including HIV, seizures, neuromuscular dysfunction, paraplegia, hypertension, depression, anxiety, and other conditions, and had an intact cognition with a BIMS score of 15. A physician’s order dated 01/04/26 directed that one 5% Lidocaine patch be applied topically to the left hip at 9:00 AM and removed at 9:00 PM. On 01/16/2026, the Medication Administration Record showed that a medication aide administered the ordered Lidocaine patch to the resident at 9:00 AM, and the aide later stated that when she applied the patch, the resident did not already have one on. Shortly thereafter, an LVN, who was also passing medications, applied an additional Lidocaine patch to the resident’s left lower hip area. The LVN reported that she had given the resident his medications, left to obtain the Lidocaine patch, and upon returning did not see an existing patch, which she stated must have been applied in the interim. She further stated that the resident, who was verbal and able to direct where he wanted the patch placed, did not inform her that a patch had just been applied. The situation was discovered when the resident reported to the DON that staff had applied an additional Lidocaine patch. The DON and the administrator both confirmed that the resident had two Lidocaine patches on his left hip, with one patch located higher up and partially covered by the resident’s briefs. The LVN later found the first patch higher on the left hip than where she had placed the second patch and stated that the patch may have moved or been moved by the resident. The facility’s Medication Management Program policy required adherence to the “8 Rights” of medication administration and specified that the same authorized person should prepare, administer, and record medications, but in this instance, two different staff members applied Lidocaine patches, resulting in a double application contrary to the physician’s order.
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