Federal inspectors discovered the medication error during a December 30 complaint investigation. Resident 1 had a scopolamine patch behind his right ear dated December 28 and an identical patch behind his left ear with smudged, unreadable writing.
The resident's physician had ordered one scopolamine patch every three days to control excess secretions. The manufacturer's instructions explicitly state: "Wear only one scopolamine transdermal system at any time."
Licensed Nurse 1 confirmed during the inspection that the resident had two patches in place. Licensed Nurse 2 acknowledged the error, telling inspectors that staff "took off the old one and put on the new one every three days" and that the resident "was not supposed to have two scopolamine transdermal patches on at one time."
But they hadn't removed the old patch.
Scopolamine patches deliver medication directly into the bloodstream through skin absorption over a controlled 72-hour period. With two patches, the resident received double the prescribed dose for an undetermined length of time.
The Director of Nursing admitted licensed nurses should have followed the doctor's orders. "If the MD order indicated a transdermal medicated patch was removed before a new medicated transdermal patch was applied, and there were two medicated transdermal patches on Resident 1, then the order was not followed," the director told inspectors.
The nursing director also acknowledged the safety implications: "It was important to follow MD orders so there were no adverse effects from medications."
The physician's order, dated September 25, was clear: "Apply 1 patch transdermally one time a day every 3 day(s) for secretion and remove per schedule." The manufacturer's instructions, updated in August 2023, specify that patches should be removed after three days before applying a new system.
The facility's own medication administration policy, dating to October 2017, requires that "medications are administered in accordance with written orders of the attending physician."
None of these safeguards prevented the double-dosing.
The inspection report doesn't indicate how long the resident wore two patches simultaneously. The December 28 date on one patch suggests he had been receiving the double dose for at least two days when inspectors arrived.
Scopolamine overdose can cause serious side effects including confusion, hallucinations, seizures, and respiratory depression. The medication is commonly used in nursing homes to reduce saliva and respiratory secretions in residents with swallowing difficulties or end-stage conditions.
Transdermal patches pose particular risks in institutional settings because they're easily overlooked during routine care. The adhesive patches can shift position, become partially detached, or remain hidden under clothing or hair. When staff don't systematically check for and remove old patches, residents can accumulate multiple doses.
Licensed Nurse 2's statement that staff routinely "took off the old one and put on the new one every three days" suggests this was an isolated oversight rather than systemic failure to follow protocols. But the consequences of such oversights in medication administration can be severe.
The inspection classified this as a minimal harm violation affecting few residents. However, federal regulators noted the "potential for actual harm" from the medication error.
The facility had no excuse for the violation. The doctor's orders were clear, the manufacturer's instructions were unambiguous, and the facility's own policies required compliance with physician orders. Multiple licensed nurses were involved in the resident's care, yet none caught the error before federal inspectors arrived.
The inspection occurred as part of a complaint investigation, though the report doesn't specify whether the medication error itself prompted the federal review or was discovered during investigation of other concerns.
For Resident 1, the discovery meant immediate removal of the extra patch and return to the prescribed single-patch regimen. But the incident raises questions about medication oversight at the 120-bed facility, particularly for residents receiving multiple transdermal medications that require careful application and removal schedules.
The violation occurred despite multiple checkpoints designed to prevent medication errors: physician orders, pharmacy guidelines, manufacturer instructions, facility policies, and licensed nurse training. Each of these safeguards failed to prevent a resident from receiving double the prescribed dose of a potent medication for an undetermined period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Bay Post Acute from 2025-12-30 including all violations, facility responses, and corrective action plans.