Failure to Monitor Fentanyl Patch Administration Leads to Overdose
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in a serious incident involving a fentanyl overdose. The deficiency was identified when a resident, who had multiple medical conditions including COPD, diabetes, hypertension, bipolar disorder, and quadriplegia, was found unresponsive and suffering from respiratory failure. The resident was admitted to the hospital with multiple fentanyl patches on his body, which had not been reported by the facility staff. This oversight led to the administration of Narcan in the emergency room to counteract the overdose. The investigation revealed that the facility did not adhere to the physician's orders for the fentanyl patch, which was to be changed every 72 hours. On the day of the incident, the resident was found with two fentanyl patches, one of which appeared to have been on for an extended period. Interviews with the facility staff, including nurses and a CNA, indicated a lack of thorough checks for existing patches on the resident's body, leading to the application of an additional patch without removing the old one. The staff involved were aware of the protocols for fentanyl patch application but failed to conduct a full body search to ensure no other patches were present. The facility's internal investigation and interviews with staff highlighted discrepancies in the documentation and communication regarding the fentanyl patches. The DON stated that the facility could account for all patches given to the resident, yet the hospital records and EMS reports contradicted this claim. The failure to properly monitor and document the administration of fentanyl patches resulted in a critical situation that required emergency medical intervention.
Removal Plan
- The Director of Nursing and/or designee has reviewed all current residents with fentanyl patch orders.
- The Director of Nursing and/or designee has observed current residents for appropriate patch placement and documentation.
- The Director of Nursing and/or designee will review new admissions to ensure that any new orders for fentanyl patch are complete and patch is placed appropriately.
- Licensed nursing staff received re-education on appropriate order, placement and documentation of fentanyl patch, including identifying signs and symptoms of possible overdose.
- Licensed Nursing Staff re-educated on appropriate disposal of Fentanyl Patches.
- Licensed Nursing Staff re-educated on validation of patch placement.
- Direct care staff re-educated on communication to supervisor of any displaced or dislodged patch, to ensure M.D. orders are followed.
- Re-education initiated with Licensed Staff and completed with Licensed staff and Direct care staff. Those that are PRN, PTO/FMLA will complete prior to next schedule shift. Re-education will continue for any new hires and as part of the orientation process.
- Re-education will be validated using employee roster.
- The Director of Nursing or designee will review the 24-hour report in the morning clinical meeting to ensure that any new orders for fentanyl patch are documented and placed appropriately. This will be an ongoing process.
- The Director of Nursing or designee will ensure new admissions have complete orders and correct placement for fentanyl patch. Placement of patches will be rotated on upper body.
- The facility does have Narcan available in the event of an overdose situation for residents who are prescribed Fentanyl.
- The Director of Nursing or designee will monitor compliance every shift, then every shift 3 times per week, then 1 x a week. The results of findings will be discussed in the monthly QAPI meeting and the plan will be continued as needed. The DON or designee will utilize a validation log to document findings.
- The Administrator will attend the morning clinical meeting to ensure the Director of Nursing or designee is reviewing the admissions and the 24-hour report in the morning clinical meeting.
- An Ad-Hoc QAPI was conducted by the Administrator, with the Medical Director, Director of Nursing, and the Regional Clinical Specialist to discuss the immediate jeopardy concerning F755 and to develop the above-mentioned plan of care.
Penalty
Resources
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A resident with chronic pain and an order for PRN oxycodone 5 mg had doses signed out on the narcotic log by an LPN on two occasions, but these doses were not documented as administered on the MAR. The DON acknowledged the discrepancy between the narcotic log and MAR and referenced a prior resident interview from another misappropriation investigation, though no documentation showed the resident was interviewed about these specific undocumented administrations. The resident reported receiving medications as requested and having no concerns with other nurses, while the facility’s controlled substances policy addressed receipt and logging of medications but did not prevent the identified documentation inconsistencies.
The facility failed to administer ordered medications to three residents despite medications being available on site and clear physician orders. One resident with diabetes, CKD, and hypertension did not receive multiple antihypertensives, psychotropics, and insulin doses on admission and the following day, and blood glucose monitoring was not performed as ordered. Another resident with Parkinson’s disease did not receive several scheduled doses of carbidopa-levodopa, with no documentation of refusal, even though the drug was in stock. A third resident with acute systolic heart failure and hypertension did not receive an ordered evening dose of carvedilol, despite vital signs not meeting hold parameters and the medication being available. The DON confirmed in each case that medications were not administered per physician orders, contrary to facility policies requiring adherence to written orders and use of on-hand medication supplies.
A resident admitted with a lumbar compression fracture and significant back pain had a PRN oxycodone order, but staff were unable to obtain the medication from the emergency supply machine due to repeated malfunctions. The nurse verified orders with the on-call provider, faxed prescriptions to the pharmacy, and administered Tylenol while the resident continued to report moderate to severe pain. Despite multiple attempts to access the emergency supply and arranging for pharmacy delivery, no oxycodone was administered, and the physician was not notified that the ordered pain medication was unavailable, contrary to facility policy requiring prescriber contact when controlled substances are delayed or not available.
A resident with anxiety and other medical conditions, care planned for safe medication use, had multiple scheduled doses of clonazepam 0.5 mg PO BID not administered as ordered, with MAR entries coded to see nurses’ notes and incomplete documentation, including one missed dose with no corresponding progress note and no narcotic sign-outs for the omitted doses. Progress notes on some days cited waiting for pharmacy supply or a new prescription. Additionally, clonazepam 1 mg tablets were available while the order was for 0.5 mg BID, and on two occasions RNs documented wasting 0.5 mg of clonazepam with only a single nurse signature and no second witness, contrary to facility policy requiring two licensed nurse witnesses and signatures for controlled substance destruction.
Surveyors determined that the facility failed to consistently follow its policy requiring two nurses to count and sign for controlled substances at shift change. Review of narcotic count sheets for several medication stations over multiple weeks showed repeated instances where a second nurse’s signature was missing, indicating that the required dual-nurse verification of narcotic counts was not documented. This issue involved all residents receiving narcotic medications during the review period and was confirmed by the facility Administrator.
Surveyors identified that an LPN administered two different ophthalmic solutions consecutively to a resident with glaucoma without waiting the manufacturer-recommended five minutes between drops, and the LPN stated she had not been trained to wait between eye drop applications. In a separate case, a resident with hypertension and a care plan for CVA related to hypertension had multiple documented systolic blood pressure readings above the ordered threshold for PRN clonidine, yet the MAR and progress notes contained no documentation that the PRN antihypertensive was administered on those occasions. The resident reported feeling his blood pressure was often too high, stated he did not recall receiving medication for high blood pressure, and reported that his cardiologist was not being informed of abnormal blood pressure readings, which the DON confirmed were not accompanied by documentation of PRN medication administration.
Inaccurate Documentation of PRN Controlled Substance Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation of controlled substances in the medical record for a resident receiving PRN opioid pain medication. The resident was admitted with hypertension and anemia and had an order for oxycodone 5 mg by mouth every four hours as needed for pain, with a care plan identifying chronic pain related to an internal orthopedic device and left knee pain. The care plan interventions included administering medications as ordered and observing for effectiveness and side effects. The resident’s MDS indicated intact cognition and that the resident had pain and received opioid medication. Record review showed that on two separate dates in February, an LPN signed out oxycodone 5 mg on the narcotic log at specific morning times, but there were no corresponding entries on the MAR indicating that the medication was administered at those times. The DON acknowledged that the LPN had signed out the medication on the narcotic log without signing it as administered on the MAR and stated they did not believe there was a concern for diversion or misappropriation, referencing an interview with the resident in another investigation. However, there was no statement in the misappropriation investigation documentation indicating that the resident had been interviewed about these specific instances of medications being signed out without MAR documentation. The resident later reported receiving medications as requested and having no concerns with other nurses. The facility’s written controlled substances policy addressed receipt, verification, and logging of controlled medications but did not prevent the discrepancy between the narcotic log and MAR documentation identified in this case.
Plan Of Correction
1. Resident #99 was interviewed by Director of Nursing on 2/25/26 and had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit 3 residents per med cart for a total of 27 residents who utilize controlled substance PRN pain medication weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Discrepancies noted during the audits will be investigated and documentation corrected to accurately reflect medicine administered. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Administer Ordered Medications Despite Availability
Penalty
Summary
The deficiency involves the facility’s failure to administer medications in accordance with physician orders for multiple residents, despite medications being available on site. One resident with type 2 diabetes mellitus with hyperglycemia, chronic kidney disease, hypertension, and hypokalemia was admitted from the hospital with a history of chronically elevated systolic blood pressure up to the 190s and severe cognitive impairment, dependent on staff for activities of daily living. Hospital discharge orders and subsequent physician orders included multiple antihypertensives, insulin aspart on a low-dose sliding scale, and several other medications. On the evening of admission, the resident did not receive ordered doses of amlodipine, hydralazine, and trazodone, and blood sugar was not monitored and insulin was not administered. The following day, the resident did not receive hydrochlorothiazide, lisinopril, morning doses of amlodipine and hydralazine, atenolol, fenofibrate, pantoprazole sodium, pregabalin, and sertraline, even though the facility’s Medication Inventory on Hand report showed these medications were available. The DON confirmed the medications were not administered per physician orders and that the nurse should have used medications on hand and clarified which medications the resident had been receiving prior to leaving the hospital. Another resident with Parkinson’s disease with dyskinesia, hypertension, atrial fibrillation, and gait and mobility abnormalities, and with severe cognitive impairment, was admitted with hospital orders for carbidopa-levodopa 25/100 mg three times daily. The physician orders at the facility also reflected carbidopa-levodopa 25/100 mg three times daily. Review of the MAR showed that the resident did not receive the evening and bedtime doses of carbidopa-levodopa on one day, and did not receive the bedtime dose the following day. The Medication Inventory on Hand report indicated that carbidopa-levodopa was available for administration, and nursing notes contained no documentation that the resident refused the medication. The DON verified that the medication was not administered as ordered, despite being available in the facility. A third resident with acute systolic heart failure, acute pulmonary edema, cardiomegaly, and hypertension, and with intact cognition, was admitted with hospital discharge orders for carvedilol 6.25 mg twice daily. The facility’s physician order mirrored this, specifying carvedilol 6.25 mg twice daily for hypertension, to be held only if systolic blood pressure was less than 100 or pulse was less than 60 beats per minute. On the evening of admission, the resident’s vital signs showed a blood pressure of 116/59 and heart rate of 84, which did not meet the hold parameters. However, the MAR indicated that the evening dose of carvedilol was not administered, and nursing notes did not document any refusal. The Medication Inventory on Hand report showed carvedilol was available, and the DON confirmed that the medication was not administered per physician orders. Facility policies required medications to be administered according to written physician orders and allowed use of on-hand medication supply when pharmacy medications were not yet delivered, but these procedures were not followed in the cited instances.
Failure to Ensure Availability of Prescribed Pain Medication and Notify Prescriber of Delay
Penalty
Summary
The deficiency involves the facility’s failure to ensure prescribed pain medication was available for administration to a resident with significant back pain. The resident was admitted with osteoporosis and a wedge compression fracture of the first lumbar vertebra and reported lower back pain rated as six out of ten shortly after admission. A baseline care plan documented that the resident was alert and oriented with short-term memory problems, required supervision for mobility and toileting, and was independent with eating. A physician’s order was in place for oxycodone 5 mg by mouth every four hours as needed for moderate pain, and one to two 5 mg tablets every four hours as needed for moderate to severe pain, for up to twenty doses in total. On the evening of admission, the nurse verified admission medication orders with the on-call provider and faxed the medication list and prescriptions, including oxycodone, to the pharmacy. The Medication Administration Record showed that the resident received Tylenol 600 mg for a pain level of six out of ten, but no oxycodone or other pain medications were documented as administered. Pain assessments documented pain levels of six out of ten at 8:30 p.m. and 9:55 p.m., and seven out of ten at 11:24 p.m. The nurse contacted the pharmacy at 9:20 p.m. to verify receipt of the oxycodone prescription and was given a code to obtain two 5 mg oxycodone tablets from the facility’s emergency supply machine. When the nurse attempted to retrieve the oxycodone from the emergency supply machine with a second nurse, the drawer malfunctioned and would not open despite multiple attempts. The nurse called the pharmacy again to report the problem and was advised to contact the DON or the machine’s support number. The nurse notified the ADON and DON and continued unsuccessful attempts to access the medication, then requested immediate delivery of oxycodone, which the pharmacy indicated would arrive in the early morning hours. The resident was informed of the situation and offered Tylenol while continuing to report pain at a level of seven out of ten. The Administrator and DON later confirmed that the nurses did not notify the resident’s physician that the oxycodone was not available, despite a facility policy stating the prescriber would be contacted when delivery of a controlled substance would be delayed or the medication would not be available.
Failure to Administer and Reconcile Clonazepam per Orders and Controlled Substance Policy
Penalty
Summary
The deficiency involves the facility’s failure to administer and reconcile a controlled medication, clonazepam, according to physician orders and facility policy for one resident. The resident was admitted with diagnoses including encephalopathy, low back pain, cervical spinal stenosis, and anxiety, and had a care plan identifying increased risk of adverse reactions related to opiate use, with interventions to administer medications as ordered and monitor for side effects. The admission MDS showed intact cognition. Physician orders for February directed clonazepam 0.5 mg PO BID for anxiety. Review of the MAR/TAR showed that multiple scheduled doses (one morning dose on the first day of the month, both morning and evening doses on the second day, and both morning and evening doses on the sixteenth day) were marked with a code indicating “Other/See Nurses Notes,” and the narcotic sign-out sheet showed no corresponding sign-outs for these doses. Progress notes lacked any entry for the missed dose on the first day, while notes on the second and sixteenth days documented that clonazepam was not administered due to awaiting medication from the pharmacy or a new prescription. The Interim DON confirmed that five doses were missed, contrary to the facility’s medication administration policy requiring medications to be given safely, timely, and as prescribed. The deficiency also includes improper handling and documentation of controlled substance wasting for the same resident’s clonazepam. The narcotic sign-out sheet showed clonazepam 1 mg available with an order for 0.5 mg BID, and entries on two consecutive days documented that RNs each wasted 0.5 mg of clonazepam but signed the waste with only a single signature and no second witness, despite facility policy requiring all controlled substance destruction to be witnessed by at least two nurses with both signatures recorded. The Interim DON confirmed that only one signature appeared for each waste event. One RN stated she always had a witness and speculated the other nurse may have walked away without signing, while the other RN reported she had not been aware at the time that two nurse witnesses and signatures were required. The facility’s controlled substance policy specified adherence to state and federal laws and required two licensed nurse witnesses and a record for each drug destruction, which was not followed in these instances.
Failure to Consistently Complete Dual-Nurse Narcotic Count Verification
Penalty
Summary
Surveyors found that the facility did not consistently ensure proper reconciliation of narcotic medications in accordance with its Controlled Substance Shift to Shift Count Policy, which required all narcotic medications to be counted and verified by two nurses at each shift-to-shift handoff, with both nurses signing the count sheet. Review of narcotic Controlled Substance Count Sheets for multiple medication stations over a period from early February to late March showed missing second nursing signatures on several dates, indicating that the required dual-nurse verification was not documented. Specifically, Station #1’s count sheet lacked a second nurse signature on one date, Station #2’s count sheet lacked a second nurse signature on three dates, and Station #4’s count sheet lacked a second nurse signature on three dates. This deficiency had the potential to affect 17 residents who received narcotic medications from the facility. During an interview, the Administrator confirmed these findings. No additional resident-specific medical histories or conditions related to this deficiency were described in the report.
Failure to Follow Ophthalmic Administration Guidelines and PRN Antihypertensive Orders
Penalty
Summary
The deficiency involves failures in pharmacy services and medication administration, including not following manufacturer instructions for ophthalmic medications and not administering an ordered PRN antihypertensive medication when clinical parameters were met. For one resident with diagnoses including unspecified dementia, essential hypertension, chronic kidney disease, mixed hyperlipidemia, and glaucoma, physician orders directed the use of brimonidine tartrate ophthalmic solution and dorzolamide-timolol ophthalmic solution, each to be instilled as one drop in both eyes twice daily. Manufacturer instructions for both ophthalmic products specified that when more than one topical ophthalmic drug is used, they should be administered at least five minutes apart. An LPN reported she did not know she was supposed to wait five minutes between eye drops, stated she does not wait, and that no one who trained her waited between eye drop applications. Surveyor observation confirmed that the LPN administered the two different eye drop solutions consecutively without waiting five minutes, and the LPN verified she did not wait between administrations. The deficiency also includes failure to administer a PRN antihypertensive medication as ordered for another resident. This resident had a history including pelvic fracture, chronic pain, PTSD, depression, epilepsy, hypertension, and a care plan focus for cerebrovascular accident related to hypertension, with interventions to monitor vital signs, notify the physician of significant abnormalities, and administer medications as ordered. A physician order directed clonidine 0.1 mg by mouth every eight hours as needed for systolic blood pressure (SBP) greater than 170. Review of the MAR showed multiple dates on which the resident’s SBP exceeded 170 (including readings of 219, 206, 183, 172, and 175), with no documentation that the PRN clonidine was administered on those dates. Further review of the resident’s progress notes from December through February revealed no documentation of administration of the ordered PRN clonidine during the periods when elevated SBP values were recorded. The resident reported concern that his blood pressure was often too high, stated that staff were monitoring his blood pressure, and reported that his cardiologist indicated no one from the facility was reporting blood pressure abnormalities. The resident also stated he could not recall receiving medications for his high blood pressure. The DON confirmed there was no documentation in the medical record of the resident receiving the PRN blood pressure medication on the dates when SBP readings were above the ordered threshold and that there were no explanatory notes corresponding to a MAR notation to “see notes.”
Plan Of Correction
F755 Pharmacy Srvcs/Procedures/Pharmacist/Records The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 22 is receiving ophthalmic drops per order with a 5-minute wait time between drops. An assessment of resident #22 was completed on 4-9-26 by the infection preventionist with no negative effects. The order was written to remind the nurses to wait 5 min between medication administration. the order was rewritten on 3/31/26 by unit manager. Resident #24 was audited on 3-31-26 by the DON and continues to receive clonidine as prescribed related to BP parameters. Resident #24 was assessed for negative effects on 4-9-26 by the infection preventionist, and none were identified How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All the residents in the facility that have eye gtt orders, there are 3 and have bp with parameters, there are 3, have the potential for this practice. A sweep of all residents with eye gtts was done 3/29/26 by nurse manager and a sweep of BP with established parameters completed 3/29/26 by the DON. These residents are in compliance with med pass. The eye gtt orders have been reviewed and written to include proper sequence of administration by MDS and ADON . Residents who have established medication parameters for blood pressure medication could also be affected by this practice but have been educated and are currently being audited for compliance What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-service all nurses in eye gtt sequencing and leave the insert with the medication to review. Additionally, nurses were in- serviced to monitor the MAR for identified parameters and follow the guidance and document. This in-service was completed 4-9-2026 How the corrective action will be monitored to ensure the deficient practice will not recur. On 3/29/26 DON/designee are auditing all residents with eye gtts 3X a week X 4 weeks for observation of medication administration with 5 min between multiple eye gtts. All of the residents with BP parameters are being audited by observation of administration and MAR 3x a week by the DON for medicating residents according to BP parameters all to ensure administration of residents with multiple eye drops will be administered at least five minutes between medicated eye drops and medication was administered according to BP parameters) Results are presented to QAPI committee weekly. If the audit reveals concerns, the nursing will be reeducated post audit.
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