F0697

E

Failure to Administer and Verify Ordered Fentanyl Patches for Multiple Residents

Indianapolis, Indiana Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered fentanyl transdermal patches and to verify their placement every shift for four residents with chronic pain or neuralgia. For one resident with chronic pain who was non-verbal and required staff to anticipate her needs, the care plan directed staff to administer medications as ordered and to verify fentanyl patch placement every shift. Physician orders required application of a 72-hour fentanyl patch every three days and verification of patch placement each shift. The MAR showed the patch was not applied on one date because the medication was unavailable, and multiple shifts in July, August, and September did not have documented verification of patch placement as ordered.

Another resident with chronic pain, who could not reliably participate in a pain interview and exhibited daily non-verbal indicators of pain, had orders for a 72-hour fentanyl patch every three days and for every-shift verification of patch placement. The MAR showed a gap between patch applications, missing two ordered applications, with one missed application documented as due to medication unavailability, and missing verification entries on specified shifts. A third resident with chronic pain had an order for a 72-hour fentanyl patch every three days and every-shift verification; the MAR documented a missed application due to the need for a new prescription and missing verification entries on two first shifts. A fourth resident with neuralgia had long-standing orders for a 72-hour fentanyl patch every three days and every-shift verification; the MAR showed at least one shift where verification of patch placement was not documented. The DNS reported there had been issues involving two nurses and fentanyl patch diversion on the unit where these residents resided.