HospitalInspections.org

Based on record review and interview the facility failed to ensure all patients receive a suicide screening in a timely manner to ensure that necessary precautions are implemented in 1 of 10 patient records reviewed (Patient (Pt) #1); and staff failed to ensure all patients receive timely/appropriate nursing assessments after receiving a Reversal Agent (Narcan) for a opioid overdose in 1 of 10 patient records reviewed (Pt #1), in a total sample of 10 medical records reviewed.

Findings Include:

Review of Narcan manufacturer guidelines for use last revised 11/2015 (Reference ID 3848912) revealed the following:
-Narcan is an opioid antagonist indicated for the emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression.
-The duration of action of most opioids may exceed that of Narcan resulting in a return of respiratory and/or central nervous system depression after an initial improvement in symptoms. Therefore, it is necessary to seek emergency medical assistance immediately after administration of the first dose of Narcan and to keep the patient under continued surveillance.

Review of "Medication Guidelines for Deep Sedation/Analgesia..." dated 08/2018 revealed that after Narcan administration, "Observe for re-sedation...Monitor patient for 2 hours after administration. May not reverse CV (cardiovascular) effects, may cause non-cardiogenic pulmonary edema (fluid in the lungs)."

Review of the policy and procedure titled, "Care of the Patient with Suicidal Ideation" last revised 07/25/2022 revealed the following:
-All inpatients and patients who present to the Emergency Department (ED) age 12 and older...will be screened to identify their risk for suicide using the designated validated tool.
-If the patient has a negative screen and there are no other factors suggestive of suicide risk, then no further screening is required.
-The RN (Registered Nurse) will initiate appropriate suicide precautions based on the result of the suicide risk screening...

Review of Pt #1's medical record revealed Pt #1 arrived in the ED via ambulance on 11/20/2022 at 10:09 pm after overdosing on opioids and being administered Narcan by EMS (Emergency Medical Services); Pt #1 was discharged home on 11/21/2022 at 2:00 am.

Review of Pt #1's "Prehospital Care Report (ambulance run sheet)" revealed that on 11/20/2022 at 9:39 pm the fire department responded to a home for a complaint of Pt #1 being "unconscious with agonal breathing" with a chief complaint of "Overdose". The Prehospital Care Report stated, "Upon arrival pt was laying on the floor and bystanders were conducting chest compressions. Compressions were stopped and pt was found to have a pulse...pt was administered nasal Narcan but breathing remained inadequate. IV (intravenous) access was established and pt was administered IV Narcan...In med unit (ambulance) pt became alert enough to answer questions. Pt claimed that (Pt #1) did not know what he had taken." Per Pt #1's Prehospital Care Report, Pt #1 was administered intranasal Narcan at 10:13 pm (19 seconds), and IV Narcan at 10:13 pm (46 seconds).

Review of Pt #1's ED Provider Notes dated 11/21/2022 at 2:51 am revealed that Pt #1 was "...brought in by EMS with police after apparent opioid overdose...(Pt #1) States that he was drinking alcohol and had some Xanax (anti-anxiety medication), does not know what kind of opiate he may have consumed."

Review of Pt #1's "Patient Care Timeline" in the ED revealed the following:
11/20/2022:
-10:09 pm: Pt #1 arrived in the ED via ambulance
-10:11 pm: Patient roomed in ED
-10:15 pm: Vital signs assessed--Blood Pressure 116/91 (120/80 is normal), Pulse 132 (60-100 beats per minute is normal), Respiratory Rate 25 (12-16 breaths per minute), Pulse oximeter (blood oxygen level) 97% (92-100% oxygenation is normal).
-10:37 pm: ED Triage Notes stated, "...Pt awake and oriented on arrival to ED, unaware of events that occurred prior to EMS arrival. Endorses use of opioids today, per friends on scene pt uses benzos (benzodiazepine/anti-anxiety medication) frequently."
-10:37 pm: Triage Completed
-10:45 pm: ED RN assessment completed including; Neurological (disoriented to situation, able to reorient, difficulty following conversation, poor attention/concentration, slow speech), Respiratory ("Within defined limits"), Cardiac (Heart rate "above parameters"), Skin (pale, cold, clammy).

11/21/2022:
12:10 am: Vital signs documented--Blood pressure 98/52, Pulse 82, Respiratory Rate 11, Pulse oximeter 94.
12:33 am: Suicide and Depression Screen completed.

Review of Pt #1's ED Patient Care Timeline revealed that there was no documented evidence of nursing staff monitoring/assessing Pt #1's vital signs on 11/20/2022 between 10:15 pm and 12:10 am (1 hours and 55 minutes), after EMS administered Pt #1 two doses of Narcan (10:13 pm--time discrepancy with EMS and ED timeline); Pt #1's vital signs were out of normal parameters at 10:15 pm (Pulse 132, Respiratory rate 25).

Review of Pt #1's ED Patient Care Timeline revealed, nursing staff performed a focused nursing assessment (Neurology, Respiratory, Cardiac, Pain, Skin) on 11/20/2022 at 10:45 pm, per review there was no documented evidence of a reassessment conducted by nursing staff between 10:45 pm and prior to Pt #1's discharge on 11/21/2022 at 2:00 am (3 hours and 15 minutes) (abnormal assessments were documented on Pt #1's initial focused nursing assessment).

Per review of Pt #1's ED Patient Care Timeline , Pt #1 did not receive a Suicide and Depression screening until 11/21/2022 at 12:10 am (1 hour and 56 minutes after triage was completed).

Per interview with Interim ED Manager B, at the time of Pt #1's medical record review on 01/06/2023 beginning at 12:00 pm, Manager B stated that the RN should have done focused nursing assessments and vital signs hourly on Pt #1, Manager B agreed that there was no documented evidence of this being done. Manager B stated that hourly assessments were based on Manager B's "understanding" and not a "standard of practice".

Per interview with Interim ED Manager B on 01/06/2023 at 1:00 pm, Manager B stated that a suicide screening should be "one of the first things the nurse does", Per Manager B this is usually done during triage.

Per interview with ED RN C on 01/06/2023 beginning at 3:23 pm, RN C stated that she/he has worked in the ED for 6 years and works in Triage. RN C stated that all patients over 12 years should get a suicide screening during triage; per RN C, if the patient comes in by ambulance and goes straight to an ED room the assigned RN should complete the patient's suicide screening on admission. RN C stated that if a patient is given Narcan, vital signs should be monitored at least every 5 to 15 minutes until patient is at baseline and than every 30 minutes thereafter.

Per Quality Manager E on 01/06/2023 at 4:00 pm, Manager E stated that there is no nursing assessment and reassessment policy for the ED.