F0755

D

Failure to Remove and Properly Document Lidoderm Patch Administration

San Antonio, Texas Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The facility failed to provide pharmaceutical services that ensured accurate dispensing and administration of a prescribed Lidoderm (lidocaine) patch for one resident. The resident was an elderly female with diagnoses including a left wrist fracture, constipation, depression, and a urinary tract infection. Her 5-Day MDS showed a BIMS score of 11 (moderately cognitively intact), frequent pain rated 5/10, and use of scheduled and PRN pain medications. Her care plan included administration of analgesics as ordered and monitoring for side effects and effectiveness. An active physician order directed that a 5% Lidoderm patch be applied to the lower back once daily for back pain and removed every evening before bedtime, consistent with manufacturer directions to use the patch for up to 12 hours within a 24-hour period.

On the medication administration record for the month, the Lidoderm patch was documented as administered on 03/07/2026 by a medication aide. During a medication pass observation the following day, an LPN entered the resident’s room to administer the scheduled Lidoderm patch and, upon exposing the resident’s lower back, observed an existing Lidoderm patch still in place. The patch was dated 03/06/2026 and had no staff initials. The LPN stated the resident should not have had the previous patch on, that she had not worked the prior two days and therefore had not seen the resident’s back, and that she believed the patch should only be on for 12 hours. She expressed uncertainty as to whether the prior day’s administration had been missed or if the patch had been misdated, and stated that such an error was unacceptable because it placed the resident at risk of receiving more medication or a higher dose than intended. When questioned, the resident reported she was not in pain and believed the patch had been applied the day before but was unsure.

In a subsequent interview, the medication aide reported working from 06:00 a.m. to 10:00 p.m. on 03/07/2026 and recalled administering the resident’s medications and applying the Lidoderm patch that day. She stated that if she applied the patch, she knew it needed to be removed in the afternoon but did not recall removing it. She remembered giving the resident evening medications and asking her to turn on her side, at which time the resident complained of arm pain; the aide believed she likely told the resident she would return and then forgot to remove the patch. She stated the patches were expected to be on for 11.5 to 12 hours and acknowledged she could have put the wrong date on the patch, noting she had previously discovered and corrected wrong dates on patches. The DON stated her expectation that staff date and initial lidocaine patches on administration and remove them after 12 hours unless the provider changed the order, and that leaving a patch on longer than expected could cause lidocaine toxicity, while not providing the patch per order could result in pain. The facility’s medication administration policy required medications to be administered in accordance with written physician orders.