Failure to Properly Order, Document, and Administer Naloxone During Change in Condition
Penalty
Summary
The facility failed to ensure services met professional standards of quality for one resident related to the ordering, documentation, and administration of naloxone. The resident had a history of hypertension, heart failure, and cerebrovascular disease and was on hospice care. A telephone order for naloxone was reportedly obtained from the physician, but there was no signed physician order in the resident’s medical record, and the order was not entered on the Physician’s Order Summary Report. The Assistant Director of Nursing (ADON) stated that a copy of the telephone order was in her office and acknowledged it had not been recorded in the resident’s chart. Facility policy required that telephone orders be transcribed onto the physician’s order form at the time the order was taken, mailed promptly to the physician for signature, and that a copy be maintained in the medical record until the signed form was returned. The facility also failed to document the administration of naloxone on the resident’s Medication Administration Record (MAR) and did not follow the facility’s opioid overdose response policy. The ADON reported that, upon finding the resident unresponsive with a relative present, she administered naloxone 4 mg nasal spray at 8:32 a.m. and a second 4 mg dose at 8:34 a.m. at the relative’s request, but did not document these doses on the MAR. Progress notes later reflected that naloxone was administered twice with no change in status and described agonal breathing and shallow respirations. The ADON further acknowledged that she did not call 911 as required by the facility’s naloxone policy, which directed staff to call 911, assess for pulse and respirations, initiate rescue breathing or CPR as indicated, and administer additional naloxone doses every two to three minutes until emergency personnel arrived.
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