River Front Rehab: Expired Fentanyl Patches Found - NJ

The violations at River Front Rehabilitation and Healthcare Center were discovered during an August inspection that revealed systematic failures in medication safety protocols.

LPN #1 administered pantoprazole to Resident #8 on the morning of August 7, six days after the medication had expired. When inspectors found the expired blister pack in the medication cart, the nurse said he "had not seen the expiration date."

The medication had been discontinued for the resident five months earlier, in March, but remained in active inventory until inspectors questioned its presence.

"Staff should check medications before the medication pass to make sure that they were not expired," the unit manager told inspectors.

But the facility's medication problems extended beyond individual oversights.

The same nurse had already signed his name as the "Offgoing Nurse" on the narcotic count record for the evening shift — hours before that shift began and without conducting the required count with an incoming nurse.

When asked why he pre-signed the controlled substance log, LPN #1 explained it was "so I do not forget."

The unit manager called the practice unacceptable. "The purpose of the narcotic count was for the incoming and outgoing nurses to document that they were in agreement that the count was correct," she said. "It was not acceptable to sign out for the outgoing shift before the count was completed."

The consultant pharmacist was blunt in her assessment. "The 7 AM to 3 PM nurse absolutely should not have signed out as the outgoing nurse on the 3 PM to 11 PM shift because they did not count with the incoming nurse," she said. "It is not okay to pre-sign."

Director of Nursing agreed: "We should never pre-sign for anything."

The most serious medication violation involved powerful opioid patches stored in the facility's automated dispensing system. During a cycle count on August 7, administrators discovered eight fentanyl patches that had expired on July 20 — nearly three weeks earlier.

The patches should have been removed on July 1, according to the facility's own policy of removing medications on the first day of their expiration month.

"The efficacy would be compromised if the medication were administered," the Director of Nursing acknowledged. She noted that both daily cycle counts and pharmacy oversight should have caught the expired opioids.

The consultant pharmacist emphasized the danger. "The potency of the Fentanyl patches would have been affected if it were expired and the resident may have received less medication if the patch were administered," she said. "There is no excuse for expired medications, they should be checking those things."

The facility also failed to follow through on pharmacist recommendations to discontinue unnecessary medications for two residents.

Resident #55 had an active order for dicyclomine, a medication for abdominal pain, despite not receiving it for more than 60 days. The consultant pharmacist recommended discontinuation in June, and the attending physician agreed in writing on July 2. But the order remained active through the inspection in August.

Similarly, Resident #89 continued receiving daily doses of Lasix, a diuretic, despite the pharmacist's June recommendation to evaluate whether the medication was still needed. The physician agreed to discontinue it on July 2, but the resident kept receiving the drug daily through the inspection.

"There is a breakdown in the MRR [medication regimen review] process, and I take that seriously," the Director of Nursing admitted.

The unit manager revealed confusion about responsibilities. "The physician is responsible for carrying out their own recommendations concerning consultant pharmacy recommendations," she said, despite facility policy requiring timely follow-through on all pharmacist recommendations.

Food safety violations compounded the facility's problems.

In the kitchen, inspectors found a significantly dented can of mushrooms stored with regular inventory rather than being removed for return. More concerning, they discovered five deep pans stacked while still wet, creating conditions for microorganism growth through a process called "wet nesting."

The facility's policy explicitly stated that items "shall never be used for drying" with towels and must "air dry" before storage.

On two nursing units, pantry freezers lacked internal thermometers and had no recorded temperatures, despite facility policy requiring daily monitoring of food storage temperatures.

"I was not aware that the freezer required a thermometer and that the temperature needed to be monitored," one unit manager said. Another admitted, "I was not aware that we had to do the freezer as well as the refrigerator."

The violations represent what inspectors characterized as a pattern of minimal harm with potential for actual harm to residents. The facility's own policies addressed most of the problems found, but implementation and oversight proved inadequate.

For Resident #8, who received expired acid reflux medication, the immediate risk was reduced effectiveness of treatment. For residents who might have received expired fentanyl patches, the consequences could have been undertreated pain from diminished opioid potency.

The pre-signed narcotic logs undermined the entire controlled substance accountability system designed to prevent drug diversion and ensure accurate inventory tracking.

River Front Rehabilitation's struggles with basic medication safety protocols highlight ongoing challenges in nursing home pharmaceutical management, where complex medication regimens and multiple staff handoffs create numerous opportunities for error.

The facility's acknowledgment of systemic breakdowns in medication review processes suggests the problems extended beyond individual mistakes to institutional failures in oversight and accountability.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for River Front Rehabilitation and Healthcare Center from 2024-08-14 including all violations, facility responses, and corrective action plans.

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