Failure to Remove Previous Rivastigmine Patch Before Applying New Dose
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications, specifically Rivastigmine (Exelon) transdermal patches, for one resident. The resident was an elderly male with Alzheimer’s disease, PTSD, GERD, and a BIMS score of 5 indicating severe cognitive impairment. His care plan identified risk for adverse side effects related to medications and noted ADL self-care deficits and impaired cognition, with interventions to administer medications as ordered and monitor for side effects and effectiveness. Physician orders directed that a 9.5 mg/24 hr Rivastigmine patch be applied transdermally once daily and removed per schedule, and the MAR specified daily removal and application times. Record review showed that on one date the Rivastigmine patch was documented as removed from the right scapula and a new patch applied to the left scapula by a medication aide, with no documentation of any patch application to the left arm. During a subsequent observation, an LVN entered the resident’s room to administer the Rivastigmine patch and, after removing the resident’s jacket and performing a skin assessment, found an existing Rivastigmine patch on the back of the resident’s upper left arm with an illegible date. The LVN then located a second Rivastigmine patch on the resident’s left scapula dated the previous day. Both patches were removed and a new patch was applied to the right upper arm. The resident, observed later in a common area, was a poor historian and unable to answer questions but did not appear to be in distress. In interviews, the LVN confirmed finding two Rivastigmine patches on the resident at the same time and stated there was an order to remove the old patch prior to applying a new one, and that staff were to document removal time, application time, and patch location. She reported she did not routinely administer medications, had not applied the patch the previous day, and routinely removed the resident’s shirt to ensure old patches were removed. The medication aide who applied the patch the prior day stated she removed a patch from the right scapula and applied a new one to the left scapula, did not recall seeing a patch on the left arm, and acknowledged she could have missed it. Facility leadership, including the ADON, Medical Director, and Interim DON, stated their expectation that staff remove old patches before applying new ones and administer medications according to physician orders and pharmacy instructions. The facility’s medication administration policy required medications to be administered as ordered by the physician, in accordance with professional standards and manufacturer specifications, and to follow the six rights of medication administration.
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