Failure to Account for and Document Receipt of Controlled Fentanyl Patch
Penalty
Summary
The facility failed to maintain a system to properly receive and account for a controlled substance (fentanyl patch) prescribed for a resident with chronic pain syndrome, seizure disorder, and depression. The resident’s MDS showed intact cognition with a BIMS score of 15/15, and the MAR contained an order for a 25 mcg/hr fentanyl transdermal patch to be applied every 72 hours for chronic pain. A pharmacy packing slip documented that one fentanyl patch was delivered and signed for by an RN on the evening of 10/25/25. The facility’s policy on controlled substances required proper handling, storage, disposal, and record keeping, including verifying medications against the packing slip, logging them, and keeping controlled substances double locked. However, there was no narcotic sheet documenting receipt of the fentanyl patch, and the facility lacked documentation of the patch’s location after it was signed in. Staff interviews and record review showed multiple breakdowns in the receipt and logging process. The RN who signed for the delivery stated she was agency staff, did not know she needed to open the package, and only placed the tote in the medication room and verbally informed another nurse that medications had arrived, without verifying contents or documenting the controlled substance. Other staff gave inconsistent or limited accounts of handling the delivery bag and medications, and one LPN reported only receiving tramadol from another nurse to place in the Cubex machine. When an LPN later attempted to apply the fentanyl patch for the resident, it was not available, and a subsequent search did not locate it. The DON stated that nurses were expected to sign in medications, verify them against the packing slip, and add a log sheet for controlled substances, but this process was not followed for the fentanyl patch, resulting in the missing narcotic and lack of required documentation.
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