F0760

D

Significant Medication Errors in Methadone, Narcan, and Antibiotic Management

Westminster, Colorado Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents remained free from significant medication errors, particularly in the management of Methadone and Narcan for one resident and antibiotic therapy for another. For the first resident, who had diagnoses including cervical vertebral fracture, functional quadriplegia, PTSD, schizophrenia, chronic pain due to trauma, and neuromuscular bladder dysfunction, an addiction provider visit on 12/18/25 documented that the resident continued to experience cravings while on Methadone 40 mg daily and ordered an increase to 50 mg daily for relapse prevention. Despite this, the facility’s computerized physician orders (CPO) for December 2025, January 2026, and February 2026 continued to list Methadone 40 mg daily until 1/20/26, and documented the indication as pain rather than relapse prevention. There were no CPOs addressing the resident’s history of substance use disorder (SUD) or orders to identify, monitor, assess, or document triggers and cravings related to SUD.

Review of narcotic count sheets and medication administration records (MARs) showed that from 12/27/25 through 1/9/26, staff administered and documented Methadone 40 mg daily, contrary to the addiction provider’s order for 50 mg daily. Narcotic count sheets dated 12/26/25–1/2/26 and 1/2/26–1/9/26 did not include the strength of Methadone received from the pharmacy, as required by the form. Later count sheets dated 1/10/26–1/16/26 and 1/16/26–1/23/26 documented Methadone 50 mg being administered, but the January MAR still showed 40 mg given through 1/20/26. The CPOs showed the order to discontinue 40 mg and start 50 mg was not entered until 1/20/26, more than a month after the external provider increased the dose. The resident’s substance abuse and psychosocial care plans contained general psychosocial and substance abuse interventions but did not include specific interventions to identify, address, monitor, or document Methadone use, SUD triggers, or cravings.

The same resident experienced an unresponsive episode on 1/26/26. A nurse note documented that at approximately 5:00 p.m. the resident was found unresponsive with a respiratory rate of 11 breaths per minute, and Narcan nasal spray was administered (one spray in each nostril) with immediate effect, followed by EMS activation and hospital transfer. Another nurse note later that evening referenced increased lethargy, disorientation, and sedation after the Methadone dose increase and a request to discuss lowering the dose, but there were no prior progress notes documenting these symptoms or provider notification before the Narcan event. The January CPOs showed a Narcan order starting 1/30/26, and there was no documented order to administer Narcan on 1/26/26 or any standing Narcan order prior to that date, despite the resident’s history of SUD and orders for Methadone and Oxycodone. The January MAR contained no documentation of Narcan administration on 1/26/26. Interviews with the LPN, DON, ADON, and PCP confirmed that Narcan was given before an order was obtained, that it was not documented on the MAR, that there was no standing Narcan order in place at the time, and that the process for updating EMR orders from external providers and maintaining complete records was inconsistent.

For the second resident, who had diagnoses including neuronal ceroid lipofuscinosis, pervasive developmental disorder, acute respiratory failure with hypoxia, and a history of recurrent pneumonia, the December 2025 MAR showed an order for Doxycycline Hyclate 100 mg by mouth twice daily for an infection from 12/24/25 through 12/31/25. The MAR contained blank administration boxes for the evening dose on 12/24/25 and the morning dose on 12/25/25, indicating the medication was not administered. The evening shift on 12/25/25 documented a “9” on the MAR, which should correspond to a progress note explaining the omission, but no such progress note was found in the EMR. A nursing progress note on 12/26/25 at 1:12 a.m. documented that the antibiotic had not arrived from the pharmacy, yet the MAR indicated the medication was administered despite its non-arrival. Another progress note on 12/26/25 at 4:48 p.m. documented that the resident was under continued monitoring for the start of doxycycline. The DON confirmed that blank MAR spaces meant the medication was not given, that there was no explanatory progress note for the missed dose on the evening of 12/25/25, and that the resident missed three doses of doxycycline.