Failure to Investigate and Account for Missing Fentanyl Patches
Penalty
Summary
The facility failed to ensure that two residents were free from misappropriation of their controlled pain medication, specifically fentanyl patches, when staff did not follow established protocols for investigating and accounting for missing patches. For one resident with significant cognitive loss and total dependence on staff for activities of daily living, a fentanyl patch was found missing during a scheduled change. The nurse and CNA searched the resident's environment but did not locate the patch, and although the Director of Nursing (DON) was notified via a communication application, no formal investigation or documentation was completed, and the nurse was not questioned further about the incident. A second resident, who had mild cognitive loss and required moderate assistance with daily activities, also experienced a missing fentanyl patch. The resident reported being in severe pain when the patch was discovered missing at the time of a scheduled change. The nurse applied a new patch, but no investigation was initiated, and the resident was not questioned about the missing patch. The DON was unaware of this incident and did not conduct or document an investigation. Interviews with facility leadership, including the DON, Medical Director, President of Clinical Operations, and Administrator, revealed that they expected missing narcotics to be reported, investigated, and documented. However, in both cases, there was a lack of follow-through on these expectations, and the missing patches were not accounted for or formally investigated, contrary to facility policy and standard practice for controlled substances.