The medication error came to light only after Resident #2 fell and staff discovered two rivastigmine patches on his body during examination. The patches, used to treat dementia symptoms, had been accumulating on the resident's skin for days.
On September 26, certified medication aide Staff F documented that she couldn't locate the resident's existing patch. Instead of conducting a complete skin assessment as required, she applied a new patch and incorrectly coded the medication record as "absence from home without meds" rather than documenting the missing patch in progress notes.
Two days later, Staff B removed what she thought was the resident's patch from his lower back and applied a new one. But she never checked the medical chart, which showed the patch should have been located on the resident's shoulder blade. The patch she removed wasn't the one she was looking for.
The following day, Staff A discovered the dangerous reality during routine care: two rivastigmine patches stuck to the resident's back.
Administrator interviews revealed this wasn't an isolated incident. On September 23, Staff G had documented being unable to find an old patch before administering a new one. The administrator told inspectors she wasn't aware of that earlier note.
When questioned about the September 26 coding error, Staff F couldn't explain why she marked the medication record incorrectly instead of documenting her inability to locate the patch. Staff B admitted she never checked the chart for the documented patch location before removing what she assumed was the correct patch.
The facility had no specific policy for transdermal patch administration, inspectors found. The administrator acknowledged this gap when asked to provide the relevant policy document.
Both medication aides received written warnings following the incident. Staff F's October 8 disciplinary record stated she "charted unable to find the Rivastigmine patch on Resident #2" and "when asked she thought it fell off, at that time she placed another patch on the resident causing a medication error."
Staff B's warning noted she "removed rivastigmine patch from Resident #2 and place a new patch on 9/29/25. After the resident fell, 2 patches were found, with one of the patches found being placed on his back by Staff B, and the other one placed on his left scapula."
The Director of Nursing told inspectors that nurses, not medication aides, should handle patch removal and application going forward. She explained that staff should never apply a new patch without locating the old one, and must conduct a complete head-to-toe visual inspection if a patch cannot be found.
Under the new protocol, nurses must document when patches cannot be located before applying replacements. All patches will be labeled with the initials of the person who applied them and the date of application.
The facility's general medication policy, last revised in 2019, requires staff to verify the right resident, medication, dosage, time and administration method before giving any medication. But it contained no specific guidance for transdermal patches, which require removal of previous doses to prevent dangerous accumulation.
Rivastigmine patches deliver medication slowly through the skin to help manage dementia symptoms. Multiple patches can cause serious side effects including nausea, vomiting, loss of appetite, and potentially dangerous drops in heart rate.
The administrator stated her expectation is clear: staff must remove existing transdermal patches or complete a thorough skin assessment to confirm no patch remains before applying a new one. The September incident prompted the facility to restrict patch administration to licensed nurses only.
Federal inspectors cited the facility for failing to ensure residents were free from medication errors, finding the incident caused actual harm to the resident involved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Luther Manor At Hillcrest from 2025-10-23 including all violations, facility responses, and corrective action plans.