Failure to Monitor and Coordinate Care for Resident on Multiple CNS Depressants
Penalty
Summary
The facility failed to ensure necessary care monitoring and interdisciplinary team (IDT) coordination to prevent respiratory depression and excessive sedation in a resident who was administered multiple central nervous system (CNS) depressant medications, including mirtazapine, oxycodone, and alprazolam. The resident had a history of chronic obstructive pulmonary disease (COPD) and was admitted with chronic hypoxic respiratory failure, requiring home oxygen. Despite pharmacy recommendations to monitor for CNS depression due to the combination of these medications, there was no documented evidence that the physician was notified for clarification or that specific monitoring parameters were established. Review of the resident's medication administration records revealed that all three CNS depressant medications were administered on multiple occasions without documentation of vital signs, such as respiratory rate and oxygen saturation, within one hour after administration. The care plan was not updated to address the risk of CNS depression, and there was no written policy or procedure for monitoring residents on multiple sedating medications. Interviews with facility staff, including the ADON, LN, DON, and pharmacist, confirmed that the recommendations for monitoring were considered vague and were not clarified with the physician, nor were specific monitoring actions implemented. The resident experienced episodes of hypoxia, lethargy, and respiratory distress, including a significant decline in oxygen saturation and use of accessory muscles for breathing, which ultimately led to transfer to a higher level of care. There was no evidence of IDT documentation addressing the resident's change in condition, and the facility's policy requiring IDT collaboration and documentation in such cases was not followed. The lack of clear monitoring protocols and failure to update the care plan contributed to the deficiency identified in the report.