The resident, who has diabetes and difficulty swallowing, told inspectors the overnight nurse "always leaves the lidocaine patch" for self-application and places all oral medications in a cup on the over-the-bed table before leaving the room.
When inspectors arrived on November 25 at 10:49 AM, they found an unopened lidocaine patch labeled from the previous night still sitting on the resident's table. The resident explained the night nurse had left it there along with oral medications, saying he takes the pills with breakfast and applies the pain patch "when he was ready" — which hadn't happened yet that morning.
The resident scored a perfect 15 out of 15 on cognitive tests, indicating no memory problems. But facility assessments determined self-administering any medications was "not appropriate" for this person, who also didn't want to handle medications independently.
More troubling, inspectors discovered this wasn't an isolated incident.
During their afternoon check at 1:16 PM, the same unopened patch remained on the table. Twelve minutes later, inspectors found a second unopened lidocaine patch on the resident's table — this one dated November 17, more than a week old.
Licensed Practical Nurse #2, identified as the regional nurse, confirmed the resident "was not to self-administer any medications, including the lidocaine patch and should not have been left at the bedside." She immediately disposed of both patches and explained to the resident that future pain medication would need to be requested from the nurse on duty.
The resident seemed confused by the sudden policy enforcement. When inspectors returned at 1:35 PM, the resident said he was "unsure of what happened to the lidocaine patch" from that morning and "was about to put the patch on but it was not there." He admitted keeping the week-old patch in his drawer as a backup, placing it on the table in preparation for application.
Licensed Practical Nurse #1, who worked the overnight shifts on both November 17 and November 25, was scheduled to work when the violations occurred. Inspectors attempted to interview this nurse but were unsuccessful.
The resident's medical orders specifically directed administering the lidocaine 5 percent patch to the lower back daily at 6:00 AM. No physician's order existed allowing self-administration of the patch or any other medications.
The resident's care plan identified him as "at risk for pain related to their physical condition" with interventions to "monitor for pain and administer medications as applicable." Yet nurses were leaving the primary pain management tool — and other medications — for unsupervised self-administration.
Facility policy explicitly prohibited this practice. The Medication Administration and Documentation policy required "all medications must be administered by the same person who prepared the dose" and mandated that medications "are not left unattended" but "kept secured in a locked area or in visible control at all times."
The resident's medical complexity made the violations particularly concerning. Beyond diabetes and swallowing difficulties, physician orders showed ongoing pain management needs requiring the daily lidocaine patches.
The inspection revealed a systematic breakdown in medication supervision. The overnight nurse repeatedly violated facility policy by preparing medications, placing them within the resident's reach, and leaving without ensuring consumption or application.
For at least eight days, this resident was essentially managing his own pain medication schedule despite facility assessments concluding he shouldn't handle any medications independently. The week-old patch sitting in his drawer suggested sporadic, unsupervised application of prescription pain medication.
The regional nurse's immediate disposal of both patches and policy clarification indicated facility leadership was unaware of the ongoing violations until inspectors discovered them during the complaint investigation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Haven Center For Nursing & Rehabilitation from 2025-11-25 including all violations, facility responses, and corrective action plans.