MONTEBELLO, CA - Federal inspectors discovered serious medication safety violations at Rio Hondo Subacute & Nursing Center involving the improper handling of powerful fentanyl patches that could expose children and adults to fatal overdoses.
Critical Fentanyl Safety Violations
The August 2024 federal inspection revealed that nursing staff failed to follow established protocols for disposing of used fentanyl transdermal patches, a Schedule II controlled substance that carries FDA black box warnings due to its potential for causing accidental fatal overdoses.
Multiple nurses admitted to throwing used fentanyl patches directly into regular trash cans without proper supervision or disposal procedures. Two Licensed Vocational Nurses told inspectors they would place removed patches inside gloves and discard them in regular waste containers without any witness present.
One nurse discovered a used fentanyl patch on a water bottle beside a resident's bed and threw it away in the trash rather than following proper disposal protocols.
Resident Places Patches on Furniture When They Fall Off
The inspection focused on a quadriplegic resident receiving continuous fentanyl patch therapy for chronic pain management. The resident told inspectors that fentanyl patches frequently fell off when removing clothing and that he would place the loose patches on his bedside table or stick them to water bottles or soda cans where he could see them.
"The fentanyl patch that fell off last night was no longer there," the resident told inspectors, stating he believed housekeeping staff had taken the patch away with the regular trash.
Nurses Unaware of Patient's Medication
During the inspection, one Licensed Vocational Nurse caring for the resident was unaware the patient wore fentanyl patches and did not know to check for their presence. When inspectors asked her to examine the resident, she confirmed no patch was present that day.
Dangerous Gaps in Medication Documentation
Inspectors discovered significant discrepancies between medication administration records and controlled drug records. Two nurses signed documentation indicating they had administered fentanyl patches on July 22 and July 25, 2024, but later admitted they had signed the records "by mistake" and never actually applied the patches to the resident.
The facility's Director of Nursing confirmed she had never received any used fentanyl patches for proper disposal and had not conducted any reconciliation to track patches from receipt through administration to destruction.
FDA Warnings About Accidental Exposure
Fentanyl transdermal patches carry FDA black box warnings specifically addressing accidental exposure risks. According to FDA labeling information, accidental exposure to even one dose can result in fatal overdose, particularly in children. The warnings state that deaths have occurred when children and adults were accidentally exposed to fentanyl patches.
The FDA emphasizes that considerable amounts of active medication remain in patches even after use, making proper disposal critical for preventing accidental exposure that could lead to serious medical problems or death.
Medical Risks of Improper Disposal
Fentanyl is approximately 80 to 100 times more potent than morphine. Even small amounts can cause respiratory depression, loss of consciousness, and death in individuals not tolerant to opioids. Children are particularly vulnerable due to their smaller body size.
When fentanyl patches are discarded in regular trash, they remain accessible to housekeeping staff, visitors, children, and other residents who might come into contact with them. The transdermal delivery system means the medication can be absorbed through skin contact, potentially causing overdose symptoms within minutes.
Application Site Rotation Failures
In addition to disposal violations, inspectors found the facility failed to rotate fentanyl patch application sites as required by physician orders. Medical records showed patches were repeatedly applied to the same location on the resident's chest for extended periods.
Proper rotation prevents skin irritation and ensures consistent medication absorption. The facility's care plan specifically noted the resident was at risk for skin complications related to the patches, yet documentation showed the same chest location was used for multiple consecutive applications.
Pharmacy Consultant Recommendations Ignored
The facility had received recommendations from their consultant pharmacist in June 2024 regarding proper accountability and disposal of fentanyl patches, but failed to implement the suggested changes. The consultant pharmacist confirmed that fentanyl patches should never be disposed of in regular trash due to remaining active medication that could expose others to adverse reactions.
Training and Oversight Deficiencies
Multiple nurses told inspectors they had received no orientation on handling controlled medications and needed additional training. Some nurses were unaware that alternative application sites beyond the chest could be used for fentanyl patches.
The Director of Nursing acknowledged she was not overseeing the handling, storage, or disposal of fentanyl patches and admitted that August 2, 2024, was the first time she had reviewed the facility's fentanyl policy.
Facility Policy Requirements
The facility's own controlled medication disposal policy, established in January 2013, requires that removed fentanyl patches be properly identified, stored, and provided to the Director of Nursing for secure storage until disposal with the pharmacist. The policy mandates that two nurses witness patch removal and application to ensure proper site rotation and prevent adverse reactions.
Regulatory Standards for Controlled Substances
Federal regulations require nursing homes to maintain strict accountability for all controlled substances from receipt through administration to final disposal. This includes detailed documentation, secure storage, and witnessed disposal procedures to prevent diversion and accidental exposure.
The violations at Rio Hondo Subacute represent failures in multiple aspects of controlled substance management, from staff training and supervision to documentation and disposal protocols.
Inspection Outcomes
The facility received citations for failing to ensure proper medication administration and failing to act upon consultant pharmacist recommendations. Both violations were classified as having potential for minimal harm but affecting facility operations and resident safety.
Federal inspectors noted the violations created serious safety risks not only for the affected resident but for anyone who might come into contact with improperly discarded fentanyl patches, including children and other vulnerable individuals.
The inspection report emphasizes that strict adherence to handling and disposal instructions is essential to prevent accidental exposure and potential fatal outcomes associated with fentanyl products.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rio Hondo Subacute & Nursing Center from 2024-08-02 including all violations, facility responses, and corrective action plans.
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