MONTEBELLO, CA - Federal inspectors documented serious medication safety lapses at Rio Hondo Subacute & Nursing Center during an August 2024 complaint investigation, revealing that nursing staff improperly disposed of used fentanyl patches in regular trash for nearly a year without oversight.
Improper Disposal of Controlled Narcotics
The investigation centered on practices surrounding fentanyl transdermal patches, a Schedule II controlled substance used for chronic pain management. Inspectors found that nursing staff had been disposing of used patches in regular trash receptacles rather than following required protocols for controlled medication destruction.
The facility had established physician orders requiring specific handling procedures for one resident receiving fentanyl patches: placement checks every 72 hours, and verification of patch removal and destruction by two nurses. However, documentation review revealed that only one nurse was initialing removal records on the facility's "Controlled Drug Record for Duragesic/Fentanyl Patch" from May through July 2024.
During interviews on August 2, 2024, the Director of Nursing acknowledged that Licensed Vocational Nurses were disposing of fentanyl patches without witnesses present. The DON stated that nurses were not providing used patches to administration for proper disposal with the consulting pharmacist, adding that "this was not happening" and that "nurses have been destroying the fentanyl in the trash" since 2023.
The DON indicated she had not been aware of these disposal practices until the inspection. She acknowledged that controlled medication fentanyl patches could be picked up by staff, other residents, or visitors, potentially leading to accidental exposure.
Fentanyl is an extremely potent opioid medication, approximately 50-100 times more powerful than morphine. Even after 72 hours of use as directed, substantial amounts of active medication remain in transdermal patches. The FDA requires manufacturers to include prominent box warnings on fentanyl products specifically addressing accidental exposure risks.
According to FDA labeling requirements, accidental exposure to even a single dose can result in fatal overdose, particularly in children. The warnings emphasize that deaths have occurred when individuals were accidentally exposed to fentanyl patches, and strict adherence to handling and disposal instructions is essential to prevent such incidents.
When patches are placed in regular trash, anyone accessing those waste containers faces potential exposure. The medication can be absorbed through skin contact or accidental ingestion. Effects of fentanyl exposure include respiratory depression, decreased oxygen levels, loss of consciousness, and death. These risks are heightened for individuals without opioid tolerance, including facility visitors and staff members not prescribed the medication.
Failure to Follow Consultant Pharmacist Recommendations
The investigation also revealed that facility leadership failed to implement recommendations from the consultant pharmacist regarding fentanyl patch handling. Monthly medication regimen reviews dated June 1, 2024, and June 20, 2024, included specific instructions to "document removal of the Fentanyl patch" and specified that "the old patch needs to be kept in the narcotic drawer in a labeled container, counted q shift and prepared to be destroyed with the other narcotics by the DON."
Despite these written recommendations appearing in multiple monthly reviews, the facility did not follow the consultant's guidance. The DON characterized this as a "system failure" during the inspection interview.
Federal regulations require nursing facilities to act upon irregularities identified during monthly medication regimen reviews. Consultant pharmacists serve as an independent check on medication practices, identifying potential safety issues before they result in resident harm. When facilities fail to implement pharmacist recommendations, they undermine this safety mechanism.
Proper protocols for fentanyl patch disposal require used patches to be folded in half with adhesive sides together, placed in FDA-cleared disposal systems or returned to pharmacies for destruction, and maintained under controlled substance security requirements until final disposition. The medication should be tracked through chain-of-custody documentation and destroyed in the presence of multiple authorized individuals.
The facility's own policy, dated January 2013 and titled "Controlled Medication Disposal," specified that fentanyl patches should be "properly identified, stored, and accounted for consistent with facility requirements for monitoring of controlled medication supplies." The policy required removed patches to be provided to the Director of Nursing or designated registered nurse for proper storage until disposal with the pharmacist.
During a telephone interview with the facility's dispensing pharmacist, the pharmacist confirmed that fentanyl patches should never be disposed of in regular trash as active medication may remain in the patch. The pharmacist stated that others could be exposed to fentanyl's effects and experience adverse reactions.
Contaminated Oxygen Equipment Reused
In a separate incident documented during the same inspection, surveyors observed infection control failures involving oxygen delivery equipment. On August 2, 2024, at 8:45 AM, inspectors found a nasal cannula marked with a date of July 24, 2024, lying on the floor of a resident's room.
The resident, admitted with diagnoses including cellulitis, type 2 diabetes, and malnutrition, required supplemental oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 92%. Assessment documentation indicated the resident required moderate assistance with personal hygiene and had intact cognitive abilities.
When inspectors returned to the room at 9:40 AM, they observed the resident receiving oxygen through the same nasal cannula that had been on the floor, still bearing the July 24 date marking.
A Certified Nursing Assistant who had been assisting the resident with personal care explained during an interview at 10:40 AM that when the resident requested oxygen during cleaning, she replaced the cannula without notifying licensed nursing staff that it had fallen on the floor. She acknowledged she should have requested a replacement cannula from nursing staff.
Nasal cannulas deliver oxygen directly into the respiratory tract. When these devices contact floor surfaces, they can become contaminated with bacteria, viruses, fungi, and other pathogens present in the environment. Reusing contaminated equipment introduces these organisms directly into vulnerable areas of the respiratory system.
The resident in this case had existing infection (cellulitis) and compromised nutritional status, factors that can impair immune function and increase infection susceptibility. Healthcare-associated respiratory infections can lead to pneumonia, increased oxygen requirements, hospitalization, and in severe cases, respiratory failure.
Standard infection prevention practices require immediate replacement of any medical equipment that contacts potentially contaminated surfaces. The Registered Nurse interviewed at 9:47 AM confirmed that the cannula should have been discarded because floor contact could lead to respiratory infection.
The facility's policy on "Changing of Nasal Cannula/Oxygen Tubing" specified that cannulas should be changed weekly and as needed if visibly soiled or damaged. The broader infection prevention policy, revised in December 2023, stated that the facility's procedures were "intended to help maintain safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections."
Additional Issues Identified
The inspection documented violations across multiple regulatory standards. Beyond the major medication safety and infection control concerns, inspectors cited the facility for failing to ensure free choice regarding attending physicians, not providing appropriate treatment and care according to physician orders and professional standards, and inadequate pharmaceutical services including failure to ensure medications were labeled correctly and stored properly.
The deficiencies identified represented breakdowns in multiple safety systems designed to protect residents. Medication management requires coordination between physicians, nurses, pharmacists, and administrators. When any component of this system fails, residents face increased risks of adverse outcomes.
Controlled substance handling involves particularly stringent requirements due to the high potential for misuse and the serious consequences of exposure. Federal and state regulations mandate specific documentation, storage, and disposal procedures. These requirements exist not only to prevent diversion but also to protect all individuals within healthcare environments from accidental exposure.
The violations occurred during a complaint investigation, suggesting that concerns about facility practices prompted the review. Federal surveyors classified the findings as causing "minimal harm or potential for actual harm" affecting "few" residents, indicating the issues were identified before documented resident injury occurred.
However, the potential consequences of the identified practices were significant. Improper fentanyl disposal created exposure risks for an indeterminate period spanning from 2023 through the August 2024 inspection. During this time, used patches containing active medication were accessible in regular trash, creating ongoing hazards for anyone handling waste or accessing disposal areas.
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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