Failure to Clarify Oxycodone Orders Resulting in Opioid Overdose and Fall
Penalty
Summary
Facility staff failed to adhere to professional standards by not clarifying overlapping and potentially conflicting oxycodone orders for a resident with complex medical conditions, including end stage renal disease, dialysis, diabetes mellitus, and congestive heart failure. The resident was admitted with significant functional dependencies and a history of pain related to a left lower extremity fracture and a large unstageable sacral wound. Physician orders included both an as-needed (PRN) oxycodone-acetaminophen and a scheduled extended-release oxycodone, but staff did not clarify the appropriateness or parameters for concurrent administration of these medications. On multiple occasions, nursing staff administered the prescribed pain medications without seeking clarification, despite the resident exhibiting increasing lethargy and changes in responsiveness. Documentation shows that the resident became progressively more lethargic after the initiation of the scheduled extended-release oxycodone, with both staff and the resident's family expressing concern. The situation escalated to the point where the resident required administration of Narcan due to suspected opioid overdose, after which the resident became agitated and suffered a fall from bed. Interviews with nursing staff and the physician confirmed that the orders should have been clarified, especially given the resident's change in condition and the risk of opioid toxicity in a patient with renal impairment. Facility policy required nurses to seek clarification for incomplete or unclear orders, but this was not done. The resident was ultimately transferred to the hospital, where he was diagnosed with pneumonia, ESRD, and opiate overdose.