Nurses Unable to Locate Prescribed Naloxone for Multiple Residents
Penalty
Summary
The facility failed to ensure that nurses were competent in locating naloxone prescribed for three residents, each of whom had a physician's order for the medication. During observations and interviews, multiple licensed nurses were unable to identify the storage location of naloxone for these residents. In each instance, the nurses, sometimes accompanied by the Director of Staff Development, searched the medication carts but could not find the naloxone. The Assistant Director of Nursing confirmed that nurses are expected to know where naloxone is stored, yet this expectation was not met. The residents involved included individuals with significant medical needs: one with cancer and impaired decision-making capacity, another with lumbar spondylosis who was cognitively intact, and a third with a spinal fracture and moderate cognitive impairment. Despite having active physician orders for naloxone, the medication was not readily accessible or locatable by nursing staff at the time of surveyor inquiry, as required by facility policy and standard practice.