Failure to Administer Ordered Naloxone for Suspected Opioid Overdose
Penalty
Summary
Facility nursing staff failed to administer ordered naloxone (Narcan) to a cognitively impaired male resident when he was found unresponsive but breathing, despite having a standing PRN order for intranasal naloxone for suspected opioid overdose. The resident’s medical record showed multiple diagnoses including metabolic encephalopathy, bipolar disorder with psychotic features, muscle weakness, and a history of falls, with a BIMS score indicating moderate cognitive impairment and a need for assistance with transfers. The MAR for the month documented a standing order for naloxone nasal spray to be given every 2 minutes as needed for suspected opioid overdose, as well as an order to monitor each shift for signs and symptoms of opioid use or overdose, with staff consistently documenting that no such signs were present. On the date of the incident, EMS was called for the resident being unresponsive; upon EMS arrival, facility staff reported that Narcan had not been administered. EMS documentation showed that the resident was unresponsive on EMS arrival and that two doses of intranasal naloxone were administered, after which the resident became alert and verbally responsive, with stable vital signs. EMS notes also recorded that an unknown nurse reported no narcotic medications had been given by the facility and that staff suspected the family might be providing drugs during visits, with a known history of substance abuse prior to admission. A CNA reported having prior suspicions that the family was bringing in street drugs, noting that the resident’s condition would change and he would become unresponsive after family visits, and that she had previously observed EMS administer Narcan with immediate improvement. An LVN confirmed that staff suspected possible drug use or opioid toxicity based on the resident’s history and symptoms of unresponsiveness and lethargy, but stated they waited for EMS because they were unsure if it was safe to give Narcan. The DON confirmed Narcan was available in the Omnicell, staff had been trained, and facility policy directed staff to call 911 and administer naloxone when opioid overdose was suspected, but it was not administered by facility staff before EMS arrival in this event.
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