F0755

E

Unaccounted Fentanyl Patches and Inaccurate Controlled Substance Documentation

Indianapolis, Indiana Survey Completed on 01-29-2026

Penalty

No penalty information released

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.