F0602

E

Misappropriation and Poor Accountability of Fentanyl Patches

Indianapolis, Indiana Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect residents from misappropriation of their narcotic medications, specifically fentanyl patches, and to ensure accurate storage, documentation, and accounting of these controlled substances. The DNS reported that approximately thirty fentanyl patches were unaccounted for and that multiple Fentanyl/Duragesic Controlled Substance Record logs were missing. The DNS stated that narcotic logs were not routinely reviewed for accuracy or completeness and were only examined when staff reported a discrepancy. She also noted that the logs that were available contained entries that did not make sense, such as an LPN documented as witnessing an RN’s fentanyl patch application despite the two not working the same shift.

For Residents C, D, E, and F, physician orders required application of 72‑hour fentanyl patches every three days, and MARs for July, August, and September documented regular application of these patches, almost exclusively by one RN and one LPN. However, for each of these residents, there were no corresponding controlled substance logs for significant time periods, and the available logs contradicted the MARs. For Resident F, there were no fentanyl logs from early July to mid‑August, and the later logs showed application dates that did not match the MARs, lacked required witnesses for removals, documented instances where no removal was recorded when a new patch was applied, and showed the RN acting as her own witness on multiple dates. Pharmacy delivery records indicated that 49 patches were delivered for Resident F, with 13 unaccounted for. A hospice clinical director reported that when hospice requested a fentanyl patch change for this resident, no patches were available despite a recent delivery.

Resident C’s MARs showed regular fentanyl patch application every three days, but there were no controlled substance logs from early July to mid‑August, and the existing logs for mid‑August through late September conflicted with the MARs. The logs showed missing witnesses for multiple removals, missing documentation of removals when new patches were applied, and the RN serving as her own witness on several dates. Pharmacy records showed 31 patches delivered for Resident C, with 4 unaccounted for. Resident E’s MARs also documented regular fentanyl patch application, with almost all applications by the same RN and LPN, but there were no logs for early July to mid‑August, and the later logs again conflicted with the MARs, showed missing witnesses, missing removals when new patches were applied, duplicate entries for the same date and time, and the RN acting as her own witness. Pharmacy records showed 40 patches delivered for Resident E, with 14 unaccounted for.

Resident D had orders for a 72‑hour fentanyl patch with shift‑by‑shift verification of placement. MARs documented regular application every three days, primarily by the same RN and LPN, but there were no controlled substance logs for early July to mid‑August or for mid‑September to late September. The available logs for mid‑August to late September conflicted with the MARs, showed application dates that did not align with the MARs, lacked witnesses for multiple removals, omitted documentation of removals when new patches were applied, and again showed the RN serving as her own witness on several dates. Pharmacy documentation indicated that 40 fentanyl patches were associated with Resident D, with 19 unaccounted for. Interviews documented in the investigative file showed that the RN acknowledged applying patches, and the LPN reported being allergic to fentanyl and stated that the RN applied the patches; the LPN also reported taking Percocet and had a positive urine drug screen for opioids during the investigation. The facility’s own policies required that controlled substances be stored, recorded, accounted for, and documented on both the MAR and the resident’s controlled substance record, with shift‑to‑shift counts and maintenance of verification forms, and defined misappropriation as wrongful use of a resident’s property or money without consent.

The DNS acknowledged that she was unsure whether the pharmacist routinely reviewed narcotic logs and that one month’s shift‑change controlled substance verification form was missing while another was undated and could not be definitively tied to a specific month. The facility’s investigation, based on pharmacy delivery records, physician orders, MARs, and the limited available controlled substance logs, concluded that there were unaccounted‑for fentanyl patches for all four residents, calculated as the difference between the number of patches delivered, the number ordered to be administered, and the number remaining. The survey findings also cross‑referenced failures to verify placement of fentanyl patches as ordered and failures to implement pharmaceutical procedures that assured accurate acquiring, receiving, dispensing, and administering of narcotic medications.