F0760

J

Significant Medication Errors Involving Fentanyl Patches and Resident Identification

El Cajon, California Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple significant medication errors related to fentanyl transdermal patch administration and resident identification. One resident with COPD, dependence on renal dialysis, Alzheimer’s disease, memory problems, and severely impaired cognitive skills was found by a hospital to have a fentanyl patch on admission, despite having no physician order for fentanyl and only being prescribed acetaminophen at the facility. The DON reported that an internal investigation determined that on 3/3/26 an LVN assigned as the medication nurse for this resident and another resident applied the other resident’s ordered fentanyl patch to this resident’s chest while providing care. On 3/4/26, the resident experienced a change in condition with increased work of breathing, low oxygen saturation, tachypnea, tachycardia, crackles in bilateral lung fields, and weak cough, leading to emergency transfer to an acute care hospital, where the fentanyl patch without an order was discovered and reported back to the facility.

A second resident, admitted with traumatic subarachnoid hemorrhage, a history of falls, a diagnosis of pain, and severe cognitive impairment, was on hospice services and had a physician’s order for a fentanyl transdermal patch every 72 hours for pain and comfort. The DON stated that on 3/3/26 this resident was scheduled to receive a fentanyl patch, but the patch intended for this resident was instead applied to the first resident. The LVN later acknowledged that he had Resident 2’s fentanyl patch with him while changing the first resident’s gastrostomy tube dressing and did not administer the ordered fentanyl patch to the correct resident, resulting in a medication omission. Another LVN reported that on 3/4/26 she was informed the second resident had not received the fentanyl patch on 3/3/26, and a skin check revealed no fentanyl patch on the resident, confirming the omission.

A further deficiency occurred during a medication administration observation for the second resident when an LVN prepared a fentanyl transdermal patch and, according to the EMAR, expected to find a previously applied patch on the resident’s right arm that needed removal before applying a new patch. During administration, the LVN applied a new fentanyl patch to the right side of the resident’s chest after failing to locate a patch on the right or left arm and did not perform a full body or skin check to verify whether a prior patch remained in place, despite acknowledging that the purpose of removal was to prevent the resident from receiving too much fentanyl. Additionally, during a separate medication pass for a third resident with chronic pain, type 2 diabetes, and intact cognition, the same LVN administered multiple oral medications, eye drops, and lidocaine patches without verifying the resident’s identity. The resident was not wearing an identification band, and the LVN did not use alternative identification methods such as checking the photograph in the EHR or confirming identity with other staff, contrary to facility policy requiring verification of resident identity before medication administration.

Surveyors determined that these failures to correctly identify residents before administering medications, to ensure medications were given only as ordered, to avoid administering one resident’s fentanyl patch to another resident without an order, to ensure an ordered fentanyl patch was not omitted, and to verify removal of a previously applied fentanyl patch before applying a new one constituted significant medication errors. The facility’s own fentanyl drug reference materials described fentanyl as a very strong opioid narcotic with a high potential for fatal overdose due to respiratory depression, and the pharmacy consultant noted that the first resident was opioid naïve and at higher risk for respiratory depression, sedation, and confusion when given fentanyl. The survey team notified the facility of Immediate Jeopardy related to the failure to identify the correct resident prior to administering a fentanyl patch and the failure to verify the location of a previously administered fentanyl patch before applying a new one, which placed the involved residents at risk for serious injury, harm, impairment, or death.

Removal Plan

• Medical Records conducted a sweep of all residents who were receiving narcotic pain patches.
• The Assistant Director of Nursing conducted a visual check to ensure narcotic pain patches were applied as ordered.
• The Medical Records Department conducted a facility-wide sweep for residents' identification bands.
• Residents who did not have an identification band were provided with one containing: name, date of birth, doctor's name, facility address, and facility phone number.
• Licensed nurses are required to check for the location of narcotic pain patches every shift so missing patches are identified prior to the next administration date.
• All licensed nurses were required to attend an in-service prior to administering any medications.