North Bay Post Acute

Based on observation, interview, and record review, the facility failed to follow physician orders for one resident (Resident 1) when licensed nurses did not remove a transdermal medicated patch (an adhesive patch that delivers a specific dose of medication through the skin and directly in to the bloodstream over a controlled period of time) before a new one had been applied.This failure had the potential to cause unwanted side effects due to a higher than prescribed dose of the medication being absorbed through the skin.Findings:During an observation on 12/30/25 at 11:52 a.m., Resident 1 was noted to have a transdermal medication patch on the skin near his right ear and an identical second transdermal medication patch on the skin near his left ear.

The patch near his right ear had the date 12/28 written on it and the patch near his left ear had writing which was smudged and unreadable.A record review of Resident 1's physician (MD) orders indicated, Scopolamine [a medication used to control excess secretions] Transdermal Patch 72 Hour, 1MG [milligram, a unit of measurement] / [every] 3DAYS (Scopolamine).

Apply 1 patch transdermally one time a day every 3 day(s) for secretion and remove per schedule.

The scopolamine patch had an order date of 9/25/25.A record review of the manufacturer's instructions for use, dated August 2023, indicated, Wear only one scopolamine transdermal system [patch] at any time.

The instructions also indicated, If the system is needed for longer than 3 days, remove scopolamine transdermal system.get a new scopolamine transdermal system and place it.During a concurrent observation and interview on 12/30/25 at 12:45 p.m., Licensed Nurse 1 (LN 1) verified Resident 1 had a transdermal medication patch in place near his left ear and an identical transdermal medication patch in place near his right ear.

During an interview on 12/30/25 at 1:42 p.m., Licensed Nurse 2 (LN 2) reviewed Resident 1's MD orders and stated Resident 1 had an order for a scopolamine transdermal patch every 3 days. LN 2 stated we took off the old one and put on the new one every three days. LN 2 also stated Resident 1 was not supposed to have two scopolamine transdermal patches on at one time.During an interview on 12/30/25 at 1:58 p.m., the Director of Nursing (DON) stated licensed nurses should have followed doctor's orders.

The DON stated 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 DON also stated it was important to follow MD orders so there were no adverse effects from medications.A review of a facility policy and procedure titled, Medication Administration - General Guidelines dated October 2017, indicated, Medications are administered in accordance with written orders of the attending physician.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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