BARDSTOWN, KY - A nursing home resident received a powerful fentanyl pain patch intended for her roommate, resulting in severe drowsiness, confusion, and a five-day hospitalization in May 2022, according to state inspection records.
Critical Medication Error Leads to Hospitalization
Staff at Signature Healthcare at Colonial Rehab & Wellness placed a 75-microgram fentanyl patch on Resident 58 on May 2, 2022, despite having no physician's order for the medication. The patch was intended for the resident's roommate. The error went undetected until emergency room staff discovered the patch during evaluation the following day.
According to facility documentation, an agency medication aide working per diem changed the roommate's fentanyl patch on May 2, 2022, documenting the application to the roommate's left shoulder. However, facility investigation revealed the patch was actually placed on Resident 58.
By May 3, 2022, staff documented that Resident 58 appeared unwell with declining mental status, difficulty staying awake, and inability to swallow medications. Emergency medical services arrived at 9:42 AM, finding the resident confused, oriented only to her own name, with oxygen saturation at 81 percent—significantly below the normal range of 95-100 percent.
The resident's hospital discharge summary dated May 10, 2024, listed her diagnosis as "encephalopathy secondary to fentanyl side effect." Rather than returning to Signature Healthcare at Colonial Rehab & Wellness, the resident transferred to a different facility upon discharge.
Understanding Fentanyl's Potency and Risks
Fentanyl is a synthetic opioid approximately 50-100 times more potent than morphine, typically reserved for patients with severe chronic pain who have developed tolerance to other opioid medications. The 75-microgram dose represents a high-strength formulation, delivered continuously through the skin over 72 hours.
When someone who has not been taking opioids regularly—termed "opioid naive"—receives fentanyl, the effects can be dangerous. The facility's pharmacist confirmed during interviews that Resident 58's symptoms were consistent with fentanyl side effects in someone not prescribed the medication. Common adverse effects documented in the fentanyl package insert include nausea, vomiting, dizziness, excessive sweating, fatigue, excessive sleepiness, and headache.
The resident's significantly decreased oxygen saturation indicated respiratory depression, a life-threatening complication of opioid medications. Fentanyl slows breathing by affecting the brain's respiratory center, and in severe cases can lead to respiratory arrest. The fact that Resident 58's oxygen levels improved from 81 to 97 percent with supplemental oxygen likely prevented a more serious outcome.
Breakdown in Safety Protocols
State regulations and the facility's own policies required staff to verify resident identity using at least two identifiers before administering medications. According to facility policy, acceptable methods included checking identification bands, verifying photographs attached to medical records, or confirming identity with other nursing personnel. The policy explicitly stated that medications supplied for one resident should never be given to another.
The Staff Development Coordinator, who was working as the second signature when the agency medication aide signed out the fentanyl patch, reported she did not observe the aide actually placing the patch on a resident. When interviewed, the agency medication aide stated she did not recall the incident or being asked about a medication error at the facility.
Facility policy also required notification of physicians and resident representatives when significant changes in physical or mental status occurred. While staff did eventually contact the physician and family on May 3, the medication error was not discovered by facility staff—emergency room personnel found the patch during their assessment.
Additional Issues Identified
Inspectors cited the facility for infection control violations when a certified nursing aide entered a resident's room without required personal protective equipment. The resident had Enhanced Barrier Precautions in place due to a pressure wound, with signage clearly posted requiring staff to wear gloves and gown for high-contact care activities. The aide admitted providing incontinence care while wearing only gloves, stating she "simply forgot" to don a gown despite receiving training on proper procedures.
State surveyors determined the medication error constituted immediate jeopardy—the most serious citation level, indicating a situation likely to cause serious injury, harm, impairment, or death to residents. The facility implemented corrective measures including medication administration system improvements, with inspectors monitoring the effectiveness of systemic changes and quality assurance activities.
According to inspection records, medication administration procedures now include a backup system with printable medication records that display both room numbers and resident photographs. The Director of Nursing confirmed staff receive education on the rights of medication administration and reporting responsibilities when medication errors occur.
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.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.