F0760

D

Significant Fentanyl Patch Dosing Error and Transcription Failures

Middletown, Connecticut Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error related to Fentanyl transdermal patches. The resident had diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, chronic respiratory failure, and congestive heart failure, and had severely impaired cognition. Physician orders from early November through late February directed application of a Fentanyl 12 mcg patch every 72 hours for pain, and controlled substance disposition records showed that 12 mcg patches were dispensed and applied on that schedule. The resident’s care plan identified actual pain related to disease process and altered respiratory status related to chronic respiratory failure, with interventions to administer medications as ordered and monitor for effectiveness and side effects.

On one shift, an agency LPN removed the resident’s Fentanyl patch a day earlier than scheduled and then realized there was no order to replace it. The LPN notified the RN supervisor, who contacted the APRN and obtained a verbal order to replace the patch and continue the 72‑hour cycle. When entering the new order into the electronic MAR, the RN supervisor inadvertently selected Fentanyl 75 mcg instead of 12 mcg and co‑signed the order herself rather than obtaining a second nurse verification. Subsequent review of controlled substance disposition records showed that no 75 mcg patches were dispensed at that time and that 12 mcg patches continued to be applied on multiple dates, while the February MAR reflected that staff were documenting administration of a 75 mcg patch on those same dates. Nursing staff continued to sign for Fentanyl 75 mcg on the MAR even though only 12 mcg patches were being dispensed and applied, and they did not fully read and verify the physician’s order against the medication packaging.

Later, the APRN refilled the Fentanyl prescription and, not recognizing that the dose in the record had been erroneously increased, accidentally refilled the prescription for Fentanyl 75 mcg instead of 12 mcg. The pharmacy then dispensed 75 mcg patches, and the first 75 mcg patch was applied to the resident. After application of the 75 mcg patch, the resident experienced a change in condition characterized by a decreased respiratory rate and low oxygen saturation on room air, which improved with repositioning and supplemental oxygen. The event was identified as a clinically significant medication dose discrepancy, with the patch in place being Fentanyl 75 mcg while the intended dose was 12 mcg. Interviews with the DNS, APRN, RN supervisor, and pharmacist confirmed that the incorrect 75 mcg order had been entered into the eMAR, that the APRN later refilled the higher dose in error, and that nursing staff failed to follow the facility’s medication administration policy and the six rights of medication administration, resulting in the resident receiving a Fentanyl 75 mcg patch instead of the ordered 12 mcg dose.