F0684

D

Late Opioid Administration and Failure to Follow Narcan Policy

Bristol, Connecticut Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer opioid pain medication in accordance with physician orders and to follow its own policy regarding naloxone (Narcan) administration and post‑administration transfer to the hospital for one resident with chronic pain syndrome and overactive bladder. The resident’s care plan called for medications to be administered as ordered and for physician notification with significant changes in pain. A standing order directed Oxycodone 2.5 mg by mouth every four hours, scheduled at midnight, 4 AM, 8 AM, 12 PM, 4 PM, and 8 PM. Review of the MAR and automated medication dispenser records showed that the 4 AM dose on the relevant date was not documented with a clear administration time, and an Oxycodone 5 mg tablet was removed from the automated dispenser at 6:30 AM, with half discarded at 6:32 AM, indicating the 4 AM dose was administered approximately 2.5 hours late. The infection control nurse and other staff confirmed that this timing was late relative to the 4 AM schedule.

Further review showed that the next scheduled Oxycodone dose, due at 8 AM, was changed to a one‑time 5 mg dose per APRN order and was administered at 9:16 AM. Pharmacy records indicated this 5 mg tablet was removed from the emergency dispenser at 9:13 AM. Staff interviews revealed that the resident’s regularly scheduled 2.5 mg dose was not available in the medication cart, prompting the supervisor to obtain an order for a one‑time 5 mg dose and to remove the medication from the emergency dispenser. The infection control nurse and RN staff noted that the interval between the 6:32 AM administration of half of a 5 mg tablet and the 9:13 AM removal of the next 5 mg tablet was less than the ordered every‑four‑hours schedule, and that the medications were not administered on time as ordered.

The deficiency also includes failure to follow facility policy regarding naloxone administration and subsequent evaluation. After the one‑time 5 mg Oxycodone dose, nursing documentation described the resident as very sedated, with low blood pressure and decreased respirations, and an APRN ordered Narcan per standing orders. The MAR showed Narcan 4 mg intranasal was administered at 12:20 PM and again at 12:40 PM, while other documentation and interviews indicated the second dose was given at 12:55 PM, significantly later than the facility’s Naloxone Standing Order, which directed that a second dose be given two to three minutes after the first if there was no or only partial response. Staff, including the infection control nurse and APRNs, acknowledged that the second dose was not given within the policy‑specified timeframe and could not identify a reason for the delay. Additionally, the facility’s Narcan Administration Policy required that residents who receive naloxone be evaluated for transport to an emergency department, but record review showed the resident was not transferred to the hospital after receiving two doses of Narcan, and staff interviews confirmed that the resident remained in the facility per APRN direction despite the policy requirement.

Title: Late Opioid Administration and Failure to Follow Narcan Policy

ShortSummary: A resident with chronic pain received Oxycodone on a schedule that did not follow the q4h physician order, with one dose given late and the next one‑time 5 mg dose administered less than four hours after the prior dose. Documentation and automated dispenser records confirmed the timing discrepancies. After the higher opioid dose, the resident became very sedated with low BP and decreased respirations, leading an APRN to order intranasal Narcan. The first Narcan dose was given, but the second dose was delayed well beyond the 2–3 minute interval required by facility policy, and the resident was not transferred to the ED for evaluation after receiving two Narcan doses, despite a written policy directing evaluation for transport following naloxone administration.