Failure to Include Naloxone in Care Plans for Residents with Physician Orders
Penalty
Summary
The facility failed to ensure that two residents with physician orders for naloxone had this medication included in their care plans. For one resident with a history of cancer and impaired decision-making capacity, the care plan for narcotic pain medication did not address naloxone administration, despite an active prescription. Similarly, another resident with lumbar spondylosis and the ability to make his own decisions also had a physician's order for naloxone, but his care plan lacked any intervention related to naloxone administration. Record reviews confirmed that both residents had current orders for naloxone, yet their respective care plans did not reflect this, omitting necessary interventions for opioid overdose reversal. The Assistant Director of Nursing acknowledged during an interview that naloxone should be included in the care plan when ordered by a physician. This omission was identified through interviews and review of facility policies, resident records, and care plans.