Failure to Prevent Significant Medication Error with Fentanyl Patch Administration
Summary
A significant medication error occurred when a resident with severe cognitive impairment and chronic pain, who had a physician's order for a Fentanyl transdermal patch, was administered a new Fentanyl patch without the removal of the previous one. The LPN responsible was unable to locate or remove the previously administered patch but proceeded to apply a new patch and did not report the missing patch at the time. This resulted in the resident wearing two Fentanyl patches simultaneously, which was not discovered until after the resident exhibited symptoms of overdose, including lethargy, inability to walk or sit upright, and drooling. The facility failed to accurately assess the resident when the change in condition was noted. The nurse who responded to the resident's altered state did not complete a head-to-toe assessment and was unaware that the resident was receiving Fentanyl. Emergency Medical Services were called, and upon their assessment, two Fentanyl patches were found on the resident, one of which was initially hidden under a blood pressure cuff. Narcan was administered, and the resident was transported to the hospital, where an accidental overdose was confirmed. Documentation and monitoring of Fentanyl patch placement were inconsistent and inaccurate in the days leading up to the incident. There were multiple instances where the location of the patch was incorrectly documented or not documented at all, and missing patches were not reported to the physician or nursing management. Staff interviews revealed a lack of standardized procedures for patch administration, removal, and documentation, as well as insufficient training and communication regarding controlled substance protocols. The facility did not initiate an incident investigation or implement immediate interventions following the discovery of the overdose.
Removal Plan
- The DON completed a skin sweep on Resident #86 to ensure there were no additional patches applied.
- The DON completed a review of Resident #86's care plan and verified to show chronic pain and potential side effects.
- The DON completed a skin sweep on a like resident (Resident #50) who had discontinued orders for Fentanyl patches. The DON verified there were no patches present.
- RNCC #302 educated the Administrator and DON on reporting risk events and initiating investigation and implementing interventions.
- The Narcotic Pain Patch Policy was updated to include: Both nurses, oncoming and off going to check placement and document in medication administration record at shift change, and removal of Fentanyl pain patch to be completed by two nurses and documented in the controlled substance/narcotic log with two nurses for disposal.
- The DON updated Resident #86's orders to include documentation of Fentanyl patch location.
- The DON updated Resident #86's order to check Fentanyl patch placement every shift to also include location observed.
- The DON provided a standard list of locations and abbreviations placed on the unit for staff reference to ensure correct abbreviation documentation.
- The DON placed a reminder sheet in the narcotic book for the nurses to physically go to check narcotic placement at shift change.
- The DON provided education on the narcotic pain patch policy to include: Checking patch physically during count and documenting in the record; disposal of patch with two nurses and to fold patch and dispose by flushing and both nurses to document on the controlled substances/narcotic log with both nurses signing the log; using the standard list of locations and abbreviations to ensure correct abbreviation of location of Fentanyl patch; and on call manager to be notified immediately if Fentanyl patch missing.
- A root cause analysis was completed by the Interdisciplinary Team (IDT) including Medical Director (MD) #102, the Administrator, the DON, Assistant Director of Nursing (ADON) #208, and RNCC #302 with an ad hoc QAPI meeting.
- Auditing includes DON or designee to review shift to shift count with physical checking of patch placement is completed, validating placement of patch to match the medical record once daily for two weeks, then four times a week for four weeks.
- Auditing to include DON or designee to audit removal of Fentanyl patch to be with two nurses and documented accurately in the narcotic log daily for two weeks, then four times a week for four weeks.
- The DON provided education to LPN #242 on completing head-to-toe assessments.
Penalty
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A significant medication error occurred when an agency RN, unfamiliar with residents and lacking clear identification procedures, administered morphine sulfate and levothyroxine ordered for one severely cognitively impaired resident to that resident’s cognitively impaired roommate, after calling out the wrong name and failing to verify identity via the electronic health record photo or another reliable method. The resident who received the wrong medications developed profound bradycardia and hypotension, was transferred to the ED with accidental opioid poisoning, and required naloxone to stabilize vital signs before returning to the facility. Surveyors also found that multiple residents lacked identification photos in the EHR despite facility policy, and staff reported relying on familiarity, resident self-identification, or room nameplates instead of a consistent, reliable process, creating a systemic breakdown in resident identification during medication administration.
A cognitively intact resident with end stage renal disease, GI hemorrhage, and anemia had ordered medications including Velphoro, sucralfate, and midodrine, but surveyors observed four medication cups containing these drugs left unattended on the bedside table while the assigned medication aide was at the cart and unable to see the resident. The aide confirmed the medications belonged to the resident, stated they must have been left from a prior shift, and acknowledged she had not yet given that morning’s doses and that staff are expected to observe residents swallowing medications. A nurse from the previous shift also denied intentionally leaving medications at the bedside but agreed this practice was inappropriate. The resident reported that nurses often left medications at the bedside without always informing him he was expected to take them. The physician stated that failure to receive these medications as ordered had the potential for significant adverse effects, and both the unit manager and DON stated that medications were not to be left at the bedside and that residents must be assessed before any self-administration is allowed.
A resident with bipolar disorder, anxiety, and depression had physician orders for 40 mg of Ingreeza daily for drug-induced subacute dyskinesia and for all medications to be crushed, consistent with the care plan directing pills to be finely crushed. During a medication pass, an LPN prepared the Ingreeza capsule softened in pudding and administered it without opening the capsule and sprinkling the contents, thereby not crushing the medication as ordered. In interviews, the LPN and facility leadership confirmed that the medication was not administered according to the physician order and that this constituted a significant medication error.
A resident with CHF and paroxysmal AFib was mistakenly given a roommate’s medications when an LPN entered a shared room, called out the roommate’s name, and administered the prepared medications to the other bed after that resident responded. The facility’s policy required licensed staff to verify resident identity using identifiers such as ID bands, photos, or staff confirmation, but this verification was not performed. As a result, the resident received multiple unintended drugs, including aspirin, Xcopri, Aptiom, levetiracetam, lorazepam, morphine, acetaminophen, carbidopa-levodopa, and gabapentin. The resident initially appeared stable but then developed lethargy and hypotension, leading to Narcan administration, EMS activation, and hospital transfer, where records confirmed accidental ingestion of the roommate’s medications with resultant lethargy and hypotension.
Two residents experienced repeated medication errors when nurses failed to administer multiple ordered medications within the facility’s required time window and, in some cases, did not administer them at all. One resident with diabetes, peripheral vascular disease, and respiratory issues repeatedly received late doses of Gabapentin, Advair, and Albuterol, and reported severe leg pain when Gabapentin was delayed. Another resident with COPD, heart failure, diabetes, and rheumatoid arthritis did not receive a scheduled lidocaine pain patch and had missing doses of Jardiance and Gabapentin during a late morning med pass, while still receiving other oral medications and an inhaler. Nursing staff and the DON acknowledged that medications are expected to be given within one hour before or after the ordered time and that late or omitted doses are not in accordance with physician orders, despite a facility policy requiring safe, timely administration and adherence to the five rights of medication administration.
A resident with a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia had IV daptomycin discontinued after imaging showed improvement, and an ID physician faxed new orders for PO levofloxacin and PO vancomycin. Although the fax was confirmed as received and scanned, nursing did not transcribe these antibiotics into the EMR or MAR, and they were not administered for approximately two months, even as the resident reported to the ID physician via telehealth that she was tolerating levofloxacin, believing she was taking it. The oral antibiotic orders did not appear in the physician order listing until after the resident was hospitalized again for fever and pain, when imaging showed recurrent discitis/osteomyelitis and the hospital continued or resumed levofloxacin and PO vancomycin. In a separate incident, an LPN administered another resident’s IV ertapenem instead of the ordered IV daptomycin to this resident after taking the wrong medication from the refrigerator, contrary to facility policies requiring medications to be administered according to physician orders and pending orders to be checked and confirmed after physician visits.
Significant Medication Error and Systemic Failures in Resident Identification
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to implement effective procedures to accurately identify residents prior to medication administration. Facility policy required that medications be administered by licensed nurses in accordance with professional standards and that residents be identified by photograph in the electronic health record before medication administration. The admission policy also required that a resident photograph be obtained and uploaded to the electronic health record to ensure accurate identification. Despite these policies, the facility did not consistently maintain resident photographs in the electronic health record and did not have a reliable alternative identification process, particularly for cognitively impaired residents and for staff unfamiliar with the residents. One critical event involved two cognitively impaired residents who shared a room. One resident, admitted with senile degeneration of the brain and a BIMS score of 5 indicating severe cognitive impairment, had physician orders for morphine sulfate concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg daily in the morning. The roommate, admitted with dementia and a BIMS score of 3 indicating severe cognitive impairment, did not have these medication orders. An agency RN, on her second shift in the facility and unfamiliar with the residents, entered the shared room to administer medications, called out the name of the resident for whom the morphine and levothyroxine were ordered, and the roommate responded "huh." Without verifying identity using a photograph or another reliable method, the nurse administered the morphine sulfate 0.5 ml and levothyroxine 25 mcg intended for the first resident to the roommate. After administering the medications, the agency RN realized at the computer that the medications had been given to the wrong resident. She immediately obtained the roommate’s vital signs, which showed blood pressure 90/50 mm Hg, heart rate 38 beats per minute, respirations 12, and oxygen saturation 98%, and contacted 911, the physician, and the resident representative. Emergency department documentation later confirmed that the resident arrived with accidental opiate poisoning and profound bradycardia, with reported heart rates as low as 29 beats per minute and low blood pressures, and required two doses of naloxone to stabilize heart rate and blood pressure before being discharged back to the facility the same day. Beyond this event, the facility’s systemic failure to maintain an effective resident identification system contributed to the deficiency. Observations showed that during medication administration, some residents did not have photographs in the electronic health record, even though the system had a designated location for such photos. Staff interviews confirmed that nurses relied primarily on electronic photographs to identify residents, but several residents lacked these photographs. Staff also reported using familiarity with residents, asking residents to state their names when cognitively intact, or relying on room nameplates, and they were unable to describe a consistent method for identifying cognitively impaired residents. Clinical record review identified multiple residents without photographs uploaded until surveyor inquiry, and staffing records showed that agency nurses comprised a portion of licensed staff, increasing the likelihood that unfamiliar staff would depend on incomplete identification tools. The DON confirmed the medication error, the reliance on photographs for identification, and that the admissions position previously responsible for uploading photographs had been eliminated, with no documented competency validation or specific training on resident identification procedures for the agency RN involved.
Plan Of Correction
Facility completed resident identification pictures in the electronic medical records for residents 48, 53, 65, 6, 7, 12, 59, 34, 23 on 4/9/2026. All resident photos uploaded and audited on same date. 2. Audit of all residents completed on 4/9/2026 to ensure photos of all residents were present in their medical chart for identification purposes. 3. Facility procedures for Medication Administration, Resident Admission Procedure and Orientation checklist for LPN/RN were reviewed and updated to reflect the taking of photographs of new residents upon admission and place in the electronic medical record for resident identification, completed on 4/9/2026. Residents received wrist bands on 4/13/2026 with exception of 5 residents who refused to have a wrist band as a secondary method of identification. Agency RN marked as a "do not return" to facility and agency was updated to mediation error on 4/7/2026. Education completed with facility licensed nurses on 4/9/2026 and ongoing on policies and procedures, resident identification, secondary identifications with use of wrist band, and 5 rights of medication administration. 4. New admission audits will be completed by the NHA/designee to ensure photo identification is uploaded to the EMR. QA committee notified of the IJ and abatement plan of correction. New admission audits for picture identification will continue daily X 2 months with results of audits to QA committee for review and alternative actions as required. DON/designee will audit nurses administering medications to ensure the 5 rights of medication pass are followed and all residents have accurate resident identification prior to medications administration is identified in 3 resident med passes, 3 X week for 4 weeks. 5. April 25, 2026
Removal Plan
- Identify residents who do not have photographs in the electronic health record.
- Take resident photographs and upload them to the electronic health record; photograph any residents not available immediately upon their return and upload promptly.
- Audit all residents’ electronic health records to verify photographs are present for identification purposes and review the system process for resident identification.
- Order wristbands for all residents containing the resident’s name and date of birth as a secondary identification method.
- Update resident photographs in the electronic health record as necessary and review them annually during resident care planning meetings by the Social Services Director or designee.
- Ensure resident photographs are taken on the day of admission and uploaded to the electronic health record, and apply a medical wristband with resident name and date of birth per the admission procedure.
- Provide education for LPNs and RNs on the five rights of medication administration and use of electronic health record photographs for resident identification, and make education on obtaining and uploading photographs available.
- Provide the agency staffing company a copy of the education materials to be completed by agency staff prior to accepting shifts and update the agency orientation packet to include the revised admission procedure and updated medication administration policy.
- Audit new admissions to ensure photographs are uploaded appropriately into the electronic health record.
- Conduct daily audits of photograph identification for new admissions for two months, and report results to the Quality Assurance Committee for review and alternative actions as required.
Medications Left Unattended at Bedside and Not Administered as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that prescribed medications were properly administered and not left unattended at a resident’s bedside. A cognitively intact resident with diagnoses including renal dialysis, end stage renal disease, gastrointestinal hemorrhage, and anemia had multiple medications ordered: Velphoro 500 mg three times daily for hypokalemia at 7:00 AM, 11:00 AM, and 4:00 PM; sucralfate 1 gram four times daily, to be given 30 minutes before meals and at bedtime; and midodrine 10 mg once daily and 5 mg twice daily, to be held if systolic blood pressure exceeded 130 mmHg. During observation, four plastic medication cups containing a large round brown tablet (Velphoro), a white oblong tablet (sucralfate), and a small white pill (midodrine) were found on the resident’s bedside table while the Medication Aide assigned to the cart was outside the room and could not see the resident. The Medication Aide confirmed the medications belonged to the resident and stated they must have been left from a prior shift’s medication pass, acknowledging she had not yet administered that morning’s medications and had not been in the room. She reported being assigned to the resident on the prior day’s 7:00 AM–3:00 PM shift but did not recall leaving medications at the bedside, and stated that medications should never be left at the bedside and residents should be observed swallowing them. A nurse assigned to the resident on the 3:00 PM–11:00 PM shift the same day also did not recall leaving medications at the bedside but agreed it was not appropriate to leave medications unattended and unsecured. The resident reported that nurses often left medications at the bedside for self-administration and did not always inform him that the medications were there or that he was expected to take them. The physician stated that the resident not receiving Velphoro, sucralfate, and midodrine as prescribed had the potential to result in significant adverse effects, and the Unit Manager and DON both stated that medications were not to be left at the bedside and that staff were expected to remain with residents to observe medication ingestion unless the resident had been assessed and approved for self-administration, which had not occurred in this case.
Failure to Properly Administer Ordered Crushed Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of Ingreeza. Facility policy on Medication Shortages/Unavailable Medications required staff to obtain medications from the pharmacy or alternate sources and to obtain alternate prescriber orders if medications were unavailable, and the resident’s care plan directed that pills be finely crushed. The resident, admitted with bipolar disorder, anxiety, and depression, had a physician’s order for 40 mg of Ingreeza once daily for drug-induced subacute dyskinesia and a separate order that medications be crushed. During a medication pass observation, an LPN prepared to administer the resident’s 40 mg Ingreeza capsule softened in pudding and failed to ensure that all medications were finely crushed, contrary to the resident’s care plan and physician order. The LPN did not open the capsule and sprinkle the contents into the pudding, and instead administered the capsule softened in pudding. In subsequent interviews, the LPN confirmed she failed to administer the Ingreeza as ordered, and the Assistant Director of Nursing confirmed that this was an inappropriate administration of the medication and constituted a significant medication error. The Nursing Home Administrator also confirmed that the facility failed to ensure residents were free of significant medication errors for this resident.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, resulting in the wrong medications being administered to one of three reviewed residents. The facility’s medication administration policy required that only appropriately licensed personnel prepare and administer medications and that the individual administering medications verify the resident’s identity using methods such as checking an identification band, checking a photograph attached to the medical record, and, if necessary, verifying the resident’s identity with other personnel. Despite this policy, an LPN entered a shared room, called out the roommate’s name, and when the resident in the other bed responded and requested assistance, the LPN proceeded to give that resident the medications intended for the roommate. The resident who received the wrong medications had diagnoses including congestive heart failure and paroxysmal atrial fibrillation. Clinical record review showed that the resident was initially assessed after the error and was alert and oriented, with vital signs including a temperature of 97.4°F, BP 105/58, HR 66, and oxygen saturation of 91%. The CRNP was notified of all medications the resident had received in error and instructed that only the resident’s Eliquis be given and all other medications held. When the LPN went to administer Eliquis, the resident was observed to be slightly lethargic, and repeat vital signs showed a BP of 85/50, temperature 98°F, HR 70, RR 15, and oxygen saturation of 92%, with continued lethargy. Further review of the clinical and hospital records revealed that the resident had been given multiple medications not prescribed for them, including aspirin 325 mg, Xcopri 300 mg, Aptiom 800 mg, levetiracetam 1500 mg, lorazepam 1 mg, morphine sulfate 0.25 ml, acetaminophen 650 mg, carbidopa-levodopa 25-100 mg two tablets, and gabapentin 600 mg. Subsequent vital signs showed a BP of 78/52 and increased lethargy, with the resident later unable to state their location. The CRNP ordered Narcan administration and later ordered the resident to be sent to the emergency department for evaluation. Hospital documentation confirmed accidental ingestion of the roommate’s medications, including Ativan (lorazepam), Keppra (levetiracetam), gabapentin, morphine, and Xcopri, with resultant lethargy and hypotension that improved with Narcan, IV fluids, and monitoring.
Failure to Ensure Timely and Complete Medication Administration for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically repeated late and omitted medication administrations for two residents with intact cognition and multiple chronic conditions. One resident reported frequently receiving medications up to three hours after scheduled times and described a day when all medications were delayed until early afternoon. This resident, admitted with diagnoses including schizophrenia, type 2 diabetes mellitus, peripheral vascular disease, and other conditions, stated he receives Gabapentin for bilateral lower leg pain and reported experiencing pain at a level of eight out of ten when his Gabapentin was delayed. A registered nurse confirmed that on one day she was the only nurse on the unit due to another nurse calling off, and that she administered this resident’s 9:00 AM Gabapentin dose at approximately 11:15 AM, outside the facility’s stated 8:00–10:00 AM window for 9:00 AM medications. Record review for this resident’s physician orders, MARs, and medication audit reports showed multiple instances of late administration of respiratory and pain medications. On several dates, Advair inhaler doses ordered for 9:00 AM and 6:00 PM were given hours late, including a 6:00 PM dose administered at 10:50 PM. Albuterol tablets ordered three times daily were repeatedly given several hours after the ordered times, such as a 9:00 AM dose given at 12:06 PM and a 1:00 PM dose given at 4:19 PM. Gabapentin 600 mg ordered three times daily for neuropathy was also administered late on multiple occasions, including a 9:00 AM dose given at 12:13 PM, a 1:00 PM dose given at 4:19 PM, and doses ordered for 11:00 AM and 4:00 PM given in the mid-afternoon and late evening. The nurse practitioner stated that medications not given within one hour before or after the ordered time are considered late and not following the doctor’s order, and that pain medications not given as ordered could result in residents being uncomfortable and having mobility affected. A second resident, admitted with diagnoses including COPD, sleep apnea, hypertensive heart disease with heart failure, heart failure, type 2 diabetes mellitus, and rheumatoid arthritis, also experienced medication administration issues. During observation, an LPN who had arrived late for her shift stated that none of the medications on her set had been passed yet and acknowledged she would not be able to complete all 9:00 AM medications within the 8:00–10:00 AM window. During a medication pass, the LPN prepared and administered multiple oral medications and an inhaler to this resident but stated that Empagliflozin (Jardiance) and Gabapentin were not available and therefore were not given. The resident, alert and oriented, reported not receiving her ordered 6:00 AM lidocaine pain patch to the left shoulder and rated her shoulder pain as eight out of ten; observation confirmed there was no pain patch in place. Review of this resident’s MAR and physician orders showed scheduled medications including a daily lidocaine patch at 6:00 AM, Bactrim DS twice daily for UTI, Hydroxychloroquine, Metformin, Symbicort inhaler twice daily, and Gabapentin three times daily for pain. The DON and nursing staff stated that medications are expected to be given within one hour before or after the ordered time, that late administration beyond this window is considered not following the doctor’s order, and that pain, hypertensive, diabetic, and antibiotic medications must be given timely as ordered. The facility’s policy on administration procedures for all medications, dated 10/25/14, states that medications are to be administered in a safe and effective manner, with review of the five rights and checking the MAR for orders. Despite this policy, the documented late administrations, missed doses due to unavailability, and failure to apply an ordered pain patch demonstrate that the facility did not consistently follow ordered times and the five rights of medication administration for these residents. Staff interviews, resident statements, and medication records collectively show that the facility did not ensure residents were free from significant medication errors related to timing and omission of ordered medications.
Failure to Transcribe and Administer Ordered Antibiotics and Wrong IV Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to transcription and administration of ordered antibiotics and the administration of another resident’s IV antibiotic. The resident had a history of lumbar discitis/osteomyelitis and chronic myeloid leukemia and had been receiving IV daptomycin via PICC line following a hospital stay. An MRI in mid-January showed improvement, and the infectious disease (ID) physician initially ordered discontinuation of IV daptomycin, PICC removal, and discontinuation of weekly labs. The following day, after further review of the MRI and inflammatory markers, the ID physician ordered a transition to oral levofloxacin 750 mg daily and oral vancomycin 125 mg daily for several weeks, including vancomycin for C. diff prophylaxis. These orders were faxed to the facility and were later confirmed by the fax company and the Business Office Manager as having been received by the facility. Despite receipt of the faxed orders, the facility did not transcribe the oral levofloxacin and oral vancomycin into the resident’s physician orders or MAR for January or February, and there was no evidence on the MAR that these medications were administered during that period. The physician order listing for the resident showed that the oral levofloxacin and vancomycin orders did not appear until mid-March, when the resident returned from the hospital with those medications ordered. During telemedicine follow-up with the ID physician, the resident reported doing well and tolerating levofloxacin, believing she was taking the ordered antibiotics, even though the MAR showed no administration. The resident, who was cognitively intact per a BIMS score of 15, later stated she only took medications provided by the facility and did not know the oral antibiotics had not been given. The Assistant DON and consultant pharmacist both confirmed that no orders for oral levofloxacin or vancomycin were received by the pharmacy or entered into the system in January or February. In March, the resident was sent to the ER with fever and left knee pain, and imaging showed extensive osseous erosion at L1-2 concerning for discitis/osteomyelitis. The hospital documentation referenced the resident as being chronically on levofloxacin and oral vancomycin for discitis and continued or resumed these medications, which were then first documented as administered at the facility in mid-March. Separately, in January, a medication occurrence report documented that an LPN administered another resident’s IV antibiotic, ertapenem, instead of the ordered daptomycin to this resident. The LPN later stated she did not check thoroughly enough and took the wrong IV medication from the refrigerator, describing it as an honest mistake and noting that previously there had only been one resident with an IV. The facility’s own policies required medications to be administered according to physician orders and required licensed nurses to check and confirm pending orders after physician visits, but the faxed ID orders for oral antibiotics were not processed, and the wrong IV antibiotic was administered on one occasion. The Medical Director stated she was not aware that the resident was supposed to start two oral antibiotics in January as ordered by the ID physician and indicated her expectation that any faxed orders for oral antibiotics would be processed and administered. The Business Office Manager described the process for handling telehealth visit notes and faxed orders, explaining that nursing staff received faxed records and placed them in a bin for scanning into the EMR under a miscellaneous tab. With assistance from the fax company, the BOM confirmed that the fax containing the orders to start oral levofloxacin and add oral vancomycin was received by the facility. The facility’s policies on medication errors and physician orders emphasized preventing significant medication errors and ensuring orders were entered and confirmed, but the failure to transcribe and administer the ordered oral antibiotics and the administration of another resident’s IV antibiotic constituted significant medication errors for this resident.
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