Unaccounted Fentanyl Patches and Inaccurate Controlled Substance Documentation
Summary
The deficiency involves the facility’s failure to implement pharmaceutical procedures that ensured accurate acquiring, receiving, dispensing, administering, and accounting of fentanyl patches for four residents with chronic pain or neuralgia. For Resident F, who had chronic pain and was newly admitted to hospice, the hospice nurse discovered that a fentanyl patch due for application was unavailable despite a recent delivery. Physician orders required a 72‑hour 25 mcg/hr fentanyl patch every three days over several periods in 2025. The MARs for July, August, and September documented regular patch applications on specific dates, almost exclusively by two nurses (an RN and an LPN). However, there were no corresponding controlled substance record logs for early July through mid‑August, and the available logs from mid‑August to late September contradicted the MARs regarding application dates. The logs also showed missing witness signatures for multiple patch removals, instances where no removal was documented when a new patch was applied, and entries where the RN signed as her own witness. Pharmacy records showed that 49 patches were delivered for this resident during the review period, with 13 unaccounted for. For Resident C, who also had chronic pain and nonverbal indicators of pain such as grimacing and facial expressions, physician orders required a 72‑hour 75 mcg/hr fentanyl patch every three days. The MARs for July through September showed patches applied as ordered, except for one date when the medication was unavailable, again almost exclusively by the same RN and LPN. There were no fentanyl controlled substance logs for early July through mid‑August. The logs from mid‑August to late September conflicted with the MARs on application dates and showed multiple patch removals without a witness, missing documentation of patch removals when new patches were applied, and instances where the RN signed as her own witness. Pharmacy documentation indicated that 31 patches were delivered for this resident in the review period, with 4 unaccounted for. The DNS later produced only one undated shift‑change controlled substance verification form for either August or September and confirmed that the other month’s form was missing. Resident E, with chronic pain and an order for a 72‑hour 25 mcg/hr fentanyl patch every three days, had MARs documenting regular patch applications in July, August, and September, almost all by the same RN and LPN. There were no controlled substance logs for early July through mid‑August. The logs from mid‑August to late September contradicted the MARs on application dates and showed multiple undocumented or unwitnessed patch removals, including several dates where new patches were applied without any recorded removal. One date showed two separate entries for patch application at the same time, and the RN again signed as her own witness on multiple occasions. Pharmacy records showed 40 patches delivered for this resident, with 14 unaccounted for. Resident D, diagnosed with neuralgia and ordered a 72‑hour 50 mcg/hr fentanyl patch every three days with shift‑by‑shift verification of patch placement, had MARs indicating regular patch applications in July, August, and September, primarily by the same RN and LPN. There were no controlled substance logs for early July through mid‑August or for mid‑September through late September. The available logs from mid‑August to late September conflicted with the MARs on application dates and showed multiple patch removals without a witness, missing documentation of removals when new patches were applied, and several entries where the RN signed as her own witness, including dates with duplicate entries. Pharmacy documentation indicated that 40 patches were administered or delivered for this resident, with 19 unaccounted for. The DNS stated that the facility’s policy required the nurse who removed the old fentanyl patch and applied the new one every 72 hours to complete the controlled substance record, with the same nurse documenting both removal and application and a different nurse serving as witness. She acknowledged that the logs did not make sense, including instances where the LPN was documented as witnessing the RN’s application despite not working the same shift. She also stated that completed logs were supposed to be filed and uploaded into the residents’ electronic records, but multiple logs were missing, particularly for Resident D’s recent deliveries. The DNS reported that no one at the facility routinely reviewed narcotic logs for accuracy or to ensure all narcotic medications were accounted for; she only reviewed them when staff reported discrepancies. The facility’s written policy on controlled substances required that administration be documented both on the MAR and on the resident’s controlled substance inventory record at the time of administration, and that shift‑change verification forms and addition/removal logs be maintained for 24 months and scanned into resident documents, but these procedures were not consistently followed for the four residents.
Penalty
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The facility failed to ensure accurate pharmaceutical services for two residents and related medication storage and recordkeeping. An LPN administered a resident’s insulin glargine pen without priming it first, and a controlled medication log for another resident’s hydrocodone-acetaminophen did not match the blister pack count. In addition, a controlled substance reconciliation log for a medication aide cart had been signed before shift change, and an expired IV tubing supply was found in the LTC medication room.
Medication Error Not Investigated or Documented: The facility failed to investigate, document, and address a reported Zepbound medication error for a resident with moderate cognitive impairment and multiple diagnoses. The event report noted a wrong dose, but the record contained no clear explanation of what occurred, no documented root cause investigation, and no documented actions taken; the DON and RN both stated the process was incomplete, and the consultant pharmacist noted the expected documentation and follow-up for medication errors.
Controlled medications were not properly tracked because the narcotic accountability sheets in one medication cart had multiple entries without the required signatures from two nurses. During the audit, RN #1 and the DON both confirmed that two nurses should have signed the narcotic count sheets.
Controlled substance records were not properly maintained for the Hall A and Hall B medication carts because shift-change narcotic count signatures were missing on multiple occasions. LVNs stated that two nurses were not verifying the count by signing the book, and the DON, ADM, and CCN confirmed that missing signatures meant there was no proof the count was completed and accurate. The facility policy required a physical inventory of controlled meds at each shift change by two licensed nurses or an allowed nurse and med aide.
Incorrect Zyprexa Dose Remained Active on MAR: A resident with psychotic disorder and hallucinations had a Zyprexa dose reduced per MD order, but the prior 10 mg order was not discontinued and both the 5 mg and 10 mg doses remained active on the MAR. The MAR showed both doses were administered daily until clarification was entered, and the LVN stated he entered the new order but thought the old order had been discontinued.
A resident with ESRD, DM2, depression, anxiety, bipolar disorder, and parkinsonism did not receive ordered Renvela for an extended period despite an active EMAR order. Review showed repeated hold periods and no doses administered across multiple months, while the dialysis RD said the medication was used for elevated phosphorus and had been filled previously. Staff interviews showed confusion about whether dialysis or the facility pharmacy should refill the medication, and the DON confirmed the medication was not readily available even though it should have been.
Pharmaceutical Services and Controlled Substance Recordkeeping Deficiencies
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs and to ensure drug records were in order for two residents, one medication cart, and one medication room. Resident #8 had diagnoses including heart failure, high blood pressure, high cholesterol, and type 2 diabetes mellitus, and his MDS documented severe cognitive impairment and insulin use. During a medication pass observation, an LVN administered 15 units of Insulin Glargine pen without priming the pen first. The LVN stated priming was important to ensure the pen was working properly and that failure to prime could affect the dose received. Resident #20 had diagnoses including asthma, depression, high cholesterol, high blood pressure, and sciatica, and her MDS documented severe cognitive impairment and active sciatica. During observation of the nurse cart, the controlled medication log for Hydrocodone-Acetaminophen 7.5-325 mg did not match the blister pack count: the log showed 6 tablets should have been available, but the pack contained 5 tablets. The LVN stated the tablet should be logged out immediately after administration. The facility also observed that the controlled medication reconciliation log for the 500 hall medication aide cart had been signed in advance of the next shift change, and the medication aide stated it should not be signed early because the cart could be taken away and something could go missing. During observation of the LTC unit medication room, an expired IV tubing supply was found on the shelves with medication equipment and supplies. The LVN stated expired items should not be in the storage room, and the DON and Administrator both stated expired supplies should not be in the medication rooms. The facility policy for insulin pen use required a safety test before each injection, and the controlled medications policy required immediate documentation after administration and a physical inventory at each shift change.
Medication Error Not Investigated or Documented
Penalty
Summary
The facility failed to ensure a reported medication error involving Zepbound for a resident with moderate cognitive impairment and diagnoses including morbid obesity, cerebral palsy, and obstructive sleep apnea was investigated, documented, and addressed in accordance with facility policy. The resident’s event report identified a wrong dose on 4/22/26, but the report did not identify any investigation into the event or any actions taken to prevent further events, and the medical record contained no further information about the incident. During interviews, the DON stated there was a lapse in the process and that an investigation was not completed. The DON reported staff explained the medication did not come from the pharmacy and that the resident did not receive the dose, although the event report stated wrong dose. RN-A also stated there was no documentation explaining what occurred or what actions were taken. The consultant pharmacist stated staff were expected to complete a thorough root cause investigation and analysis, with follow-up and detailed documentation for any medication error, including resident assessment, physician notification when indicated, monitoring for adverse effects, and measures to prevent recurrence. The facility policy stated that when a medication error occurs, the licensed nurse provides any necessary immediate care and notifies the attending provider and resident or resident representative when nursing or medical intervention, observation, or treatment is indicated, and that medication errors are tracked and trended for quality improvement purposes.
Incomplete Narcotic Count Documentation
Penalty
Summary
Controlled medications were not tracked and kept secure from potential theft and/or diversion because the facility failed to ensure the narcotic accountability sheets were properly signed by licensed nurses. During a medication cart audit, multiple dates were found on the narcotic accountability sheets without a documented on-coming or off-going licensed nurse signature, including several entries in late April, May, and early June. RN #1 stated that two nurses should have signed the narcotic accountability sheet and had not, and the DON also stated that two nurses should have signed off on the narcotic count sheets.
Missing Controlled Substance Count Signatures on Medication Carts
Penalty
Summary
The facility failed to determine that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for the Hall A and Hall B medication carts. During record review, the narcotic books for both carts were found to have missing signatures documenting shift-to-shift controlled substance counts. On the Hall A medication cart, signatures were missing on 12/30/2025, 1/1/2026, 1/2/2026, 1/19/2026, 1/26/2026, 1/30/2026, 1/31/2026, 2/12/2026, 3/9/2026, 3/11/2026, 3/26/2026, and 4/2/2026. On the Hall B medication cart, signatures were missing on 5/3/2026 and 5/30/2026. During interviews, LVN G and LVN F stated that two nurses were not verifying the narcotic count by signing the book and that, if the count was off, there would be no way to know who to contact or verify that two nurses had counted the medications. The DON stated that when the narcotic book lacks signatures, the count could be incorrect and directly affect the medications the resident receives. The ADM stated missing shift-count signatures can result in an inaccurate count and lead to missing medication doses for residents. The CCN stated that without the narcotic sheet signatures, there is no physical proof that a medication count was completed and accurate. The facility policy required a physical inventory of controlled medications at each shift change by two licensed nurses or an allowed nurse and medication aide, documented on an audit record or accountability record.
Incorrect Zyprexa Dose Remained Active on MAR
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of Resident #32 when the facility failed to discontinue an old Zyprexa 10 mg order after the dose was changed to 5 mg in the evening. Resident #32 was admitted with a diagnosis of psychotic disorder with hallucinations and was documented as rarely/never understood with severely impaired cognition. The resident’s care plan addressed psychotropic medication use and gradual dose reduction considerations, and a pharmacy recommendation was made to decrease Zyprexa from 10 mg to 5 mg in the evening, which was signed by the physician on 5/22/2026. The active order summary showed both Zyprexa 5 mg and Zyprexa 10 mg as active, and the MAR showed both doses were administered daily from 5/22/2026 until a clarification order was entered on 6/3/2026. During interview, LVN A stated he received the dose reduction order, notified the hospice provider, entered the new 5 mg order, and thought he had discontinued the 10 mg order, but did not know why it remained active. The DON stated the charge nurse was responsible for entering new orders into the MAR and later obtained clarification from hospice regarding the medication dose.
Failure to Provide Ordered Phosphate Binder
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administration of medications for Resident #59, who was admitted with ESRD, type 2 diabetes mellitus with unspecified complications, depression, anxiety, bipolar disorder, and parkinsonism. The resident’s annual MDS showed a BIMS score of 15, indicating intact cognition. Review of the EMAR showed an order for Sevelamer Carbonate (Renvela) 800 mg, 1 tablet by mouth before meals for disorders of phosphorus metabolism, with a start date of 04/17/2026, but the resident did not receive the medication from 04/18/2026 through 04/30/2026. Further review of the May 2026 EMAR showed the same Renvela order with multiple hold periods, and the resident did not receive any doses during that month. Review of the June 2026 EMAR showed the medication remained on hold and had not been administered from 06/01/2026 through the time of review. The dialysis RD stated the resident was on a fluid restriction and was prescribed Sevelamer Carbonate because of elevated phosphorus, that dialysis and the facility communicated through forms and faxed orders, and that the medication had been filled last on 03/27/2026 and 04/20/2026. Staff interviews revealed the facility believed dialysis normally refilled the medication, but the pharmacy said it could fill it if needed. The DON stated she did not know the resident had gone without the medication and confirmed the facility did not have it readily available even though it should have.
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