Medication Error Rate Exceeds 5% Due to Improper Lidocaine Patch Documentation and Removal
Penalty
Summary
The deficiency involves the facility’s failure to ensure medication error rates remained below 5%, with surveyors identifying 2 errors in 32 opportunities (6.25%). Facility policy required medications to be administered safely, timely, and as prescribed, in accordance with good nursing principles and practices. For one resident, physician orders directed application of 4% lidocaine patches to the left and right hip at bedtime, to be on for 12 hours and off for 12 hours, with removal per schedule. The MAR showed that nursing staff documented application of the patches at 8:00 PM on January 12, 2026. The following morning, the staff nurse stated she had no concern signing off on removal of the lidocaine patches before checking whether the two patches were present and reported that no LNA had told her they removed the patches. She then documented completion of the removal order on the electronic MAR at 7:59 AM on January 13, 2026. Observation at 9:14 AM showed the same nurse entered the resident’s room to administer oral medications and did not check for or remove the lidocaine patches before or after the medication pass. For another resident, physician orders directed application of a 4% lidocaine patch to the mid-back at bedtime for pain, with removal every morning. The MAR showed that nursing staff documented application of the lidocaine patch at 8:00 PM on January 12, 2026. During observation the next morning at 9:24 AM, the staff nurse entered the resident’s room to administer oral medications and attempted to remove the lidocaine patch but was unable to locate it. Despite not confirming that the patch was present or removed, the nurse documented on the MAR that the removal order had been completed. In an interview, the DON confirmed that the lidocaine patch orders for both residents were not completed as ordered and that the RN erred in documenting removal of the patches on the MAR.
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