Failure to Hold CNS-Depressant Pain Medications and Monitor Resident With Altered Mental Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and timely implement NP orders to hold multiple CNS-depressant pain medications and to initiate increased monitoring for a resident with altered mental status. The resident had multiple standing orders for CNS-depressant medications, including pregabalin, tizanidine, baclofen, suboxone, tramadol, gabapentin (PRN), and naproxen (PRN), which were being administered as prescribed. On one morning, after wound care at 8:20 AM, the resident became lethargic and was noted by the ADON to be sleeping and lethargic for the remainder of the day. The ADON reported this to the NP multiple times that afternoon and evening, describing the resident as lethargic, slow to respond, and moaning with movement instead of yelling as usual. In response to these reports, the NP gave a series of telephone/verbal orders on the same day to hold baclofen, then tizanidine, and later to hold suboxone and tramadol until the resident was more responsive. However, these orders were not transcribed onto the POS and were not implemented as directed. The MAR shows that the night-shift nurse administered suboxone at 9:00 PM and baclofen at midnight, despite the NP’s earlier orders to hold these medications due to the resident’s altered mental status. The ADON later stated she was not aware that these medications had been given and believed no oral medications had been administered since the morning dose. By the following morning, the resident remained lethargic and slow to respond even to a sternal rub, and the NP was again notified. The NP then ordered transfer to the hospital for a higher level of care. The private ambulance report documented that the resident was unresponsive to verbal stimuli and had been declining since the previous day. At the hospital, the resident presented with altered mental status, lethargy, nonverbal status, diaphoresis, dry mucous membranes, hypoxia, and later worsening hypoxia and low blood pressure, leading to intubation and ICU admission. Hospital diagnoses included gabapentin-induced toxicity, baclofen overdose, and toxic metabolic encephalopathy. Reference materials cited in the report note that combining suboxone with other CNS depressants such as baclofen, gabapentin, pregabalin, tizanidine, and tramadol can cause serious, life-threatening respiratory depression and increased sedation, and that such combinations require close monitoring.
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