Failure to Notify Physician After Resident Overdose and Narcan Administration
Penalty
Summary
Facility staff failed to notify a resident's physician after the resident experienced a significant change in condition, specifically lethargy, pinpoint pupils, and unresponsiveness, which led staff to suspect an overdose and administer Narcan. The resident, who had a history of seizures and was assessed as alert and cognitively intact on the baseline care plan, was subsequently transferred to a local hospital for evaluation. Documentation showed that staff are required to report changes in condition to the DON and physician, and to document any physician contact and response. Despite these requirements, there was no documentation that the physician was notified of the incident. Interviews with the administrator, DON, and the physician confirmed that the physician was not informed, and the physician stated that he was unaware of the overdose and had not adjusted the resident's medications as a result. The charge nurse reported faxing a nonemergent line but did not call the physician, and there was no confirmation that the fax was received. The facility's policy and care plan expectations for physician notification were not followed in this case.