Failure to Properly Notify Guardian After Resident Fentanyl Overdose and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s court‑appointed guardian in a timely and effective manner after the resident overdosed on fentanyl, required emergency treatment, and was sent to the hospital. The resident had diagnoses including paranoid schizophrenia, bipolar disorder, and a history of traumatic brain injury, and had a court‑appointed guardian whose phone number, email, and address were listed in the admission record. On the date of the incident, progress notes documented that Narcan nasal spray was administered at 6:48 p.m. and again at 6:53 p.m., after which the resident took a deep breath, and the guardian was documented as notified at 6:58 p.m. The facility’s suspected abuse investigation documented that at approximately 6:40 p.m. the resident overdosed on an illicit substance, received two doses of Narcan, became alert and oriented, and was transported by ambulance to the hospital for further evaluation. Agencies notified were listed as the Department of Health and Senior Services, the provider, and the resident’s guardian. However, subsequent email communications showed that when the Social Services Director later emailed the guardian about an appointment, the guardian responded that the resident had personally informed the guardian about being sent to the hospital for a fentanyl overdose and that no one from the facility had contacted the guardian’s emergency cell or any deputy to report the overdose or hospital transfer. The guardian reported that only a voicemail had been left on the office line in the evening, with no indication that a return call was needed, and that there was no follow‑up contact from the facility the following day. The Administrator and DON later acknowledged that the nurse on duty had called a number and left a voicemail, but it was not the emergency number, and that the nurse had been unable to locate the emergency number at the time. The DON stated that leaving a voicemail was considered a notification and that the original public administrator was the only emergency number listed, while the guardian stated that multiple emergency contact options, including an emergency cell and a main switchboard, had been provided previously. These actions and omissions resulted in the guardian not being promptly and effectively notified of the resident’s fentanyl overdose and transfer to the hospital, contrary to the facility’s notification policy requiring prompt notification of the resident’s representative for significant changes in condition and transfers.
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