Failure to Protect Resident from Misappropriation of Fentanyl Patches
Penalty
Summary
The facility failed to protect a resident’s property by not preventing the misappropriation of the resident’s prescribed opioid pain medication patches. The resident had moderate cognitive impairment, with a BIMS score of 9, and diagnoses including low back pain, age-related osteoporosis, and limitation of activities due to disability. Her MDS documented opioid use, and her physician’s orders and EHR reflected an active order for a 25 mg fentanyl patch over a specified period. During this time, staff later identified that two fentanyl patch packages associated with this resident were found empty, with the packages appearing to have been cut open, the patches removed, and the packages placed back into the box and taped shut. The facility’s own investigation documentation, titled as a criminal act and medication diversion investigation, confirmed that on a specific date an RN discovered the two empty fentanyl patch packages that appeared tampered with. This discovery led to the determination that the resident’s fentanyl patches were missing from their packaging, indicating misappropriation of the resident’s medication. The facility’s abuse prevention, reporting, and investigation policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a patient’s belongings or money without consent, and required immediate measures upon receiving such a report. The events described show that the resident’s ordered fentanyl patches were wrongfully removed from their packaging without the resident’s consent, constituting misappropriation of the resident’s belongings.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.