F0554

D

Failure to Complete Methadone Self-Administration Evaluations Prior to Dosing

New Britain, Connecticut Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete required self-administration of medication evaluations before residents began self-administering Methadone, a controlled substance, as required by facility policy. For one resident with diagnoses including opioid dependence, adjustment disorder, and anxiety disorder, the quarterly MDS showed moderately impaired cognition with independence in ADLs, bed mobility, transfers, and ambulation. The resident’s care plan identified increased risk for pain due to a history of substance use disorder and use of Methadone for treatment, with interventions focused on anticipating pain needs and coordinating with the contracted treatment agency. Despite this, the clinical record showed that a Medication Self-Administration Evaluation had not been completed since several months prior.

After a hospital discharge and readmission, a physician’s order directed Methadone 10 mg once daily with approval for supervised self-administration. The Methadone Chain of Custody Record showed the resident received Methadone from multiple dates, and a nurse’s note documented that a nurse inadvertently selected the wrong Methadone bottle, administering 120 mg instead of the prescribed 10 mg. The APRN was notified and the resident was transferred to the ED for evaluation and monitoring due to significant overdose risk. The record confirmed that no updated Medication Self-Administration Evaluation had been completed at that time. Following another hospital discharge and readmission, the resident again received Methadone doses before a new Medication Self-Administration Evaluation was completed, which occurred two days after readmission and after two doses had already been administered.

A second resident, with diagnoses including long-term use of opiate analgesic and a wedge compression fracture of the first lumbar vertebra, was documented on admission as alert and oriented to person, place, time, and situation, requiring limited assistance with transfers and being independent with bed mobility. The Methadone Chain of Custody Record showed this resident received Methadone 120 mg daily over a span of about 20 days. A physician’s order approved supervised self-administration of Methadone, but the clinical record did not contain a Medication Self-Administration Evaluation until many days later, after approximately 20 doses had already been given. The care plan later identified risk for substance use disorder with a history of substance use and Methadone utilization. The DON stated that self-administration evaluations were required on admission, readmission, and upon initiation of new Methadone orders, and acknowledged that these evaluations should have been completed prior to any resident self-administering Methadone. Facility policies on residents receiving Methadone, self-medication, and the schedule of evaluations all directed that a self-administration evaluation be successfully completed prior to the first administration and at specified intervals, which did not occur for these residents.