HOT SPRINGS, SD - Two hospice patients at Seven Sisters Living Center experienced severe pain and withdrawal symptoms after pharmacy data entry errors led to missed fentanyl patch doses over multiple days.
Critical Medication Errors Affected Hospice Patients
The July 2024 federal inspection revealed that both residents requiring fentanyl patches for end-stage conditions went without proper pain management due to a pharmacy computer system error that fundamentally changed their medication schedules.
One patient receiving hospice care for stage 5 kidney failure missed four fentanyl patch applications over 13 days. Her patch, which should have been replaced every 72 hours (3 days), remained unchanged from June 8 through June 21. The second patient, a hospice resident with terminal breast cancer and severe cognitive impairment, missed two applications over seven days.
The pharmacy had incorrectly entered the medication orders, changing the frequency from every 72 hours to every 72 days - a mistake that removed the medications entirely from daily administration schedules.
Impact on Vulnerable Residents
The medication errors had immediate and severe consequences for both patients. The cognitively intact resident reported experiencing intense back pain and debilitating migraines during the period without proper medication.
"I started having pain and looked at the calendar and found out it hadn't been changed in several weeks. It was supposed to be changed every three days," the resident told inspectors. She described the withdrawal period as particularly difficult, stating, "It was a doozy for a few days. It was a hell of a migraine."
The resident became so distressed by her pain that she called a friend, reportedly crying due to her increased symptoms. Her concerns extended beyond her own experience - she worried about the second affected resident who had dementia and could not advocate for herself.
Fentanyl Patches and Pain Management
Fentanyl patches represent a critical component of pain management for hospice patients, delivering controlled amounts of powerful opioid medication through the skin over precise time periods. The patches must be replaced exactly as prescribed to maintain consistent pain relief and prevent withdrawal symptoms.
For hospice patients managing end-stage conditions, uninterrupted access to prescribed pain medication is essential for quality of life and dignified care. Withdrawal from fentanyl can cause severe physical and psychological distress, including intense pain, nausea, anxiety, and other debilitating symptoms.
The medication errors at Seven Sisters occurred because the electronic medication administration records (MAR) no longer displayed the fentanyl orders as daily tasks. Since the pharmacy had changed the frequency to every 72 days instead of every 72 hours, the computer system removed these medications from staff's daily medication lists entirely.
System Failures and Oversight Gaps
The inspection revealed significant gaps in the facility's medication verification and monitoring systems. The pharmacy staff member who made the data entry errors did so for both residents' orders, suggesting a systematic rather than isolated problem.
The error went undetected for extended periods, indicating inadequate oversight of controlled substance administration. For hospice patients requiring complex pain management, such oversights can dramatically impact their remaining quality of life.
Corrective Actions and New Safeguards
Following the discovery of these medication errors, the facility and its pharmacy partner implemented multiple corrective measures. These included requiring two-person verification for all medication orders and printing physical medication administration records to verify accuracy.
The facility also established a daily fentanyl patch monitoring system, separate from regular medication administration records, to ensure proper tracking of these critical medications. All nursing staff and medication aides received education on the new monitoring procedures in July 2024.
The pharmacy increased its medication error review frequency from monthly to weekly meetings that now include nursing administration, quality assurance teams, and safety personnel. Officials also discussed re-implementing a dedicated medication error committee to provide additional oversight.
Industry Standards and Expectations
Federal regulations require nursing homes to ensure residents remain free from significant medication errors. For controlled substances like fentanyl, facilities must maintain precise administration schedules and comprehensive monitoring systems.
The medication administration process should include multiple verification steps, particularly for controlled substances and medications critical to patient comfort. Electronic systems require regular auditing to ensure accurate data entry and proper scheduling.
The inspection determined this violation represented past non-compliance, as the facility had implemented comprehensive corrective actions and demonstrated no additional fentanyl medication errors following the changes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Seven Sisters Living Center from 2024-07-25 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.