R58 had no order for fentanyl but received her roommate's 75-microgram patch on May 2, 2022. The next morning, staff found R58 lethargic, confused, and struggling to swallow medications. Her oxygen levels dropped to 81 percent.
Emergency medical workers discovered R58 sitting in her wheelchair, oriented only to her name. They placed her on oxygen, which improved her breathing to 97 percent, and rushed her to the hospital.
In the emergency room, a nurse found the unmarked fentanyl patch stuck to R58's left upper chest. The patch had no initials, date, or time written on it. Hospital staff called the nursing home to ask about the medication.
The facility's assistant director of nursing called back and confirmed a medication error had occurred. R58 had received the patch intended for her roommate on May 2 at 9:00 AM.
R58's discharge summary listed encephalopathy secondary to fentanyl side effects as her primary diagnosis. She remained hospitalized for five days and was discharged to another facility instead of returning to Colonial Rehab.
The resident who should have received the patch, R2, had severe dementia and an active order for the 75-microgram fentanyl patch to be changed every three days. R2's medication records show the patch was properly documented as applied to the left shoulder on May 2.
Federal inspectors found the error created immediate jeopardy to resident health and safety.
The Kentucky medication aide who made the error worked for an outside agency and came to the facility on a per-diem basis. When inspectors interviewed her in 2024, she said she didn't recall R58, had never placed a fentanyl patch on any resident, and didn't remember any incident involving putting medication on the wrong person.
The aide also said she didn't recall ever being asked about a medication error at the facility.
A staff development coordinator who worked with the agency aide that day told inspectors she was the second signature required when the aide signed out the fentanyl patch from the controlled drug supply. But the coordinator said she didn't actually watch the aide place the patch on any resident.
The coordinator noticed R58 seemed sleepier than usual later on May 2 but said the resident still answered questions without difficulty. Staff continued monitoring R58 and called the physician the next day when her drowsiness increased.
Fentanyl is a synthetic opioid 50 to 100 times more potent than morphine. The 75-microgram patch delivers a continuous dose through the skin over three days. Common side effects include nausea, vomiting, dizziness, constipation, excessive sweating, fatigue, confusion, and dangerous respiratory depression.
The facility's pharmacist told inspectors the symptoms R58 experienced were consistent with fentanyl side effects in someone who was "opioid naive" — meaning that person wasn't prescribed the medication or had only recently used opioid drugs. He said there were no obvious interactions with R58's other medications, but the concern was giving someone a sudden dose of fentanyl at that strength.
R58's medication records from May 1-3, 2022, showed she had only Tylenol 325 milligrams ordered every four hours as needed for mild pain. She had no physician orders for any fentanyl patch.
The facility's medication administration policy required two resident identifiers and triple medication verification before giving any medication. The policy stated identifiers could include checking identification bands, photographs attached to medical records, or verifying identity with other nursing staff. The policy specifically warned that medications for one resident should never be given to another.
The director of nursing told inspectors the facility used multiple identifiers including pictures of residents on medication records, names on room doors, resident names and birthdates, and verification with other staff. After medication errors, staff received education on the rights of medication administration and reporting responsibilities.
The administrator said his expectation was for staff to properly identify residents before giving medications. He said medication errors were reviewed during monthly quality assurance meetings.
But the facility made multiple unsuccessful attempts to contact the agency aide after discovering the error. Inspectors couldn't reach the former director of nursing who was on duty during the incident because the facility was unable to locate contact information.
The facility reported the medication error to the state and completed an event form. Staff notified both the physician and R58's family about what happened.
By 2024, the facility had implemented a backup system for medication administration that included printable records with room numbers and resident photographs.
In a separate violation, inspectors found a certified nursing aide failed to wear required protective equipment when caring for a resident with enhanced barrier precautions. The aide entered the room of R43, who had a pressure wound requiring special infection control measures, without putting on the required gown.
The aide told inspectors she forgot to put on the gown while changing the resident's adult brief, though she did wear gloves. She said she remembered the requirement as soon as she left the room and saw the state surveyor. The aide reported herself to the director of nursing and received additional isolation training.
The facility's enhanced barrier precautions policy required staff to wear gloves and gowns for high-contact care activities including changing briefs or helping with toileting. A sign posted on R43's door clearly outlined the protective equipment requirements.
Federal inspectors completed their survey on July 11, 2024, finding the facility had failed to ensure safe medication administration and proper infection control procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Signature Healthcare At Colonial Rehab & Wellness from 2024-07-11 including all violations, facility responses, and corrective action plans.
Additional Resources
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