145278
11/03/2023
Citadel of Sterling,the
105 East 23rd Street Sterling, IL 61081
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor the removal and placement of a pain patch. This applies to one of three residents (R1) reviewed for medications in the sample of 10.
Residents Affected - Few The finding include: The facility face sheet for R1 shows diagnoses to include type 2 Diabetes, chronic kidney disease, and wedge compression fracture of her lumbar vertebra. The facility assessment for R1 dated 9/11/23 shows her to be cognitively intact and requires supervision and set up help for her activities of daily living. The Physician orders for October 2023 shows an order for one narcotic pain patch to be applied every three days. A nursing note dated 10/16/23 shows R1 was complaining of dizziness, nausea and vomiting, and her blood pressure was high. R1 was sent to the local emergency room. A hospital history and physical dated 10/17/23 completed by R1's primary Physician shows R1 was found to be wearing two narcotic pain patches rather than one while in the emergency room on [DATE]. The report assessment shows elevated cardiac enzymes and possible drug overdose. On 11/2/23 at 10:40 AM, R1 said she had to go to the emergency room last week due to not feeling well. R1 said her doctor told her she had two pain patches on, and she had overdosed on the medication. R1 said she is not aware of how this could have happened. On 11/2/23 at 11:46 AM, V5 R1's Physician said R1 was transferred to the hospital for altered mental status and was found to be wearing two narcotic pain patches rather than one. V5 said he was told by facility staff that sometimes R1 will remove her patch and then reapply it herself. V5 said when a nurse is scheduled to change the patch, the old patch must be found and removed before another one can be applied. On 11/2/23 at 11:52 AM, V6 Licensed Practical Nurse (LPN) said she was the nurse that sent R1 to the hospital on [DATE]. V6 said R1 was complaining of being dizzy and her blood pressure was very high. V6 said she was not aware R1 was wearing two narcotic pain patches. V6 said it is not routine to check the placement of a residents pain patch once it has been applied. On 11/2/23 at 1:10PM, V7 Registered Nurse (RN) said when a narcotic pain patch is scheduled to be changed, the old one should be removed before putting on the new one. V7 said it is not routine for them to check the placement of the narcotic pain patch after it has been applied. On 11/2/23 at 1:15 PM, V4 LPN said she works night shift and is responsible for applying the narcotic pain patches. V4 said she does not know how R1 ended up with two pain patches on at the same
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145278
145278
11/03/2023
Citadel of Sterling,the
105 East 23rd Street Sterling, IL 61081
F 0760
time.
Level of Harm - Minimal harm or potential for actual harm
On 11/2/23 at 1:45PM, V2 Director of Nursing said the old pain patch should be removed before a new pain patch is applied to a resident. V2 said she is not aware how R1 was found to have two pain patches on. V2 said she expects the nursing staff to check the placement of the pain patch every shift and this should be on the residents medication administration record to remind the nurses. V2 said it was not on R1's and she was not sure why it was not on R1's.
Residents Affected - Few
R1's October 2023 MAR shows an order for Fentanyl 75mcg transdermal patch every 72 hours. The facility Medication Administration Record (MAR) for October 2023 shows R1 had the narcotic pain patch placed on 10/3/23, 10/6/23, 10/9/23, 10/12/23 and 10/15/23. The MAR does not show to check the placement of the patch every shift. The hospital Discharge summary dated [DATE] for R1 shows a final diagnosis of altered mental status, nausea and vomiting, possible drug overdose, elevated troponin (protein released into the blood stream during a heart attack), type 2 diabetes and obesity. No treatment for drug overdose was completed and further testing for cardiac problems and abdominal issues were done. The facility policy dated 1/1/22 for prescribing, administration and disposal of Fentanyl transdermal systems shows 7. date and initial patch before application to the skin. 8. Remove old patch. Used patches will still contain active medication and can be absorbed by personnel who touch patch during disposal. Wear gloves. The nurse should document the removal on the MAR. A second nurse should witness and document the removal and destruction of the old patch and initial the MAR, when possible.
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