Failure to Remove Fentanyl Patch as Ordered Resulting in Duplicate Opioid Patches
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders and the facility’s medication administration policy requiring drugs to be given in accordance with written orders. The physician order and MAR for one resident in November 2025 directed that a 12 mcg/hr fentanyl patch be applied transdermally every 72 hours for pain management and removed per schedule. Documentation showed a patch was applied on 11/26/25 at 5:25 PM and was due to be removed 72 hours later on 11/29/25 at 4:19 PM. Instead, a “9” was entered on the MAR on 11/29/25 at 3:22 PM, which should have been accompanied by a progress note, but no such note was found. The resident’s care plan identified them as receiving high-risk opioid medication and directed staff to administer pain strategies and medications per MD order and MAR/TAR. On 11/30/25 at 6:00 AM, another 12 mcg/hr fentanyl patch was documented as applied to the resident’s right arm, with no documentation that the original patch had been removed. The DON later confirmed that the order indicated the patch should have been removed on 11/29/25, that the physician order was not followed, and that there was no progress note or MAR prompt showing removal of the old patch. A nurse practitioner reported that when the resident arrived at the emergency room on 12/1/25, the ER nurse found two 12 mcg/hr fentanyl patches on the resident. The resident’s diagnoses included multiple serious conditions such as neoplasm-related pain, malignant neoplasms of bone and bone marrow, secondary neoplasms, pulmonary embolism, morbid obesity, protein-calorie malnutrition, neuromuscular bladder dysfunction, and pressure-induced deep tissue damage.
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