Complaint Investigation Report

Hospice notes on 6/5/22 indicated a Temporary Travel Hospice Nurse (H1) went to visit R1 for a Fentanyl patch change and refill, notes indicated R1 did not have a Fentanyl patch on, a caregiver helped assess R1 and both were unable to locate the patch. The nurse placed a new patch on R1’s right upper arm and notified Facility Director. 6/5/22 Resident 2 (R2) Hospice notes state R2 does not have a fentanyl patch on, H1 assessed R2’s skin with caregiver help and both were unable to locate the Fentanyl patch. H1 placed new patch with Tegaderm on upper right arm. H1 informed the Resident Services Director about the missing patch. On 6/2/22 a Fentanyl patch was applied to R2’s left upper arm. The Hospice Manager stated there was not note of a Tegaderm being applied and explained to LPA that Tegaderm is an extra sticky protector usually placed on top of IVs. Hospice notes for Resident 3 (R3) from 5/29/22 indicate that the Fentanyl patch was not found on R3, a new patch was applied and Resident Services Director was notified.

LPA interviewed Resident Services Director who stated they were aware of R2 and R3 missing a patch but not R1. The Resident Services Director called the primary Hospice Nurse (H2) regarding the missing patches the following day who said that patches fall off all the time, and to not worry about it. LPA interviewed Hospice Nurse (H2) who stated that their patient R3 has lost their Fentanyl patch twice but it had always been found. On 6/1/22 during the visit with R3 the missing patch was found on R3’s arm and two patches were present. The other time it was lost a few months ago H2 found it in the laundry. H2 explained that they have been working at the facility as a Hospice Nurse for over 3 years and believes there is no dispersion whatsoever. H2 explained that fentanyl patches fall off “all the time”, they are sticky and will stick to sheets and blankets which end up in the laundry.

LPA Olson interviewed a medtech who stated that they present with the Hospice Nurse (H1) during a visit with R3. The medtech witnessed no patch on R3 and states that they looked everywhere for it. The medtech could not recall what date this occurred but remembers the Hospice Nurse stating that it might have fallen off so they applied a Tegaderm on top of the Fentanyl patch to protect it.

LPA Olson was not able to interview Resident 1 because they had passed away on 7/21/22. Resident 2 was unable to be interviewed because they were non verbal. LPA interviewed Resident 3 who stated that their pain was managed well. R3 was not sure if they had fentanyl patches but they do remember something being on their arm. R3 does not remember if it ever fell off. LPA requested R3s MAR which shows R3 Fentanyl patch was discontinued on 6/8/22. Based on interviews and record review the allegation is deemed unsubstantiated at this time. Exit interview conducted. Report issued via email to Administrator.