Failure to Investigate Resident Overdose Incident
Penalty
Summary
Facility staff failed to conduct an investigation after a resident experienced an overdose involving Benzodiazepines and Opiates, resulting in the administration of Narcan and subsequent transfer to a hospital. The facility's investigation policy requires prompt and thorough investigation of such incidents, including interviews, assessments, and root cause analysis. However, review of the resident's medical record revealed no documentation of an investigation following the event. The resident, who was alert, cognitively intact, and on chronic opiate therapy for cancer-related pain, was found lethargic, with pinpoint pupils and unresponsive, prompting staff to administer Narcan and call emergency services. Interviews with facility leadership revealed that the Administrator was only partially informed about the incident and did not initiate an investigation due to lack of full details. The DON was not aware of the incident at all and stated that an investigation should have been started to rule out medication errors, the need for medication adjustments, or possible abuse. The absence of an investigation following the overdose event was contrary to the facility's own policy and expectations.