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Based on interviews and document review, the facility failed to ensure the nursing staff provided continuous pulse oximetry monitoring (a test used to measure the oxygen level of the blood) in a patient receiving high-alert intravenous (IV) opiate medication (pain reducing medication) in one of three medical records reviewed of patients receiving IV opiates (Patient #1).

Findings include:

References:

According to the package insert for hydromorphone hydrochloride (an opiate medication), a precaution warning read, serious, life-threatening, or fatal respiratory depression may occur. Monitor closely, especially upon initiation or following a dose increase. The insert further read, the terminal half-life of hydromorphone after an intravenous dose is about 2.3 hours. The insert further stated in patients with severe renal impairment hydromorphone appeared to be more slowly eliminated with a longer terminal elimination compared to patients with normal renal function.

According to the Lippincott Procedures - Safe medication administration practices guidelines, revised 5/20/22, for patients receiving IV opioid medication, frequently monitor respiratory rate, sedation level, and oxygen saturation level by continuous pulse oximetry or exhaled carbon dioxide by continuous capnography to decrease the risk of adverse reactions associated with IV opioid use. If adverse reactions occur, respond promptly to prevent treatment delays.

1. The facility failed to ensure nursing staff monitored the patient's pulse oximetry following the administration of hydromorphone, a high-alert IV opiate.

A. Document review

i. On 12/8/22, the facility leadership identified the national standards of practice for nursing staff as outlined in Lippincott. On review of the Lippincott Procedures - Safe medication administration practices guidelines, revised 5/20/22, for patients receiving IV opioid medication, frequently monitor respiratory rate, sedation level, and oxygen saturation level by continuous pulse oximetry or exhaled carbon dioxide by continuous capnography to decrease the risk of adverse reactions associated with IV opioid use. If adverse reactions occur, respond promptly to prevent treatment delays.

ii. Review of the medical record for Patient #1 revealed the patient was admitted on 11/14/22 for pneumonia, empyema (a collection of pus in the cavity between the lung and the membrane that surrounds it which was caused by an infection), a lower extremity wound, type 2 diabetes, and end-stage renal disease for which she received intermittent dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). According to the review of provider orders, Patient #1 was ordered continuous heart telemetry monitoring (a device used to record and transmit cardiac readings), and vital signs assessment including pulse oximetry routinely every four hours. A set of vital signs were documented at 8:48 a.m. which reported a blood pressure of 106/45, a pulse of 95, a respiratory rate of 20, a temperature of 37.6 degrees and an oxygen saturation of 98%, titrated on 2-3 liters of oxygen by nasal cannula. On 11/26/22 at 9:19 a.m., a dose of hydromorphone (an opioid used to treat moderate to severe pain) 1 mg IV was administered to Patient #1 after she reported severe pain in her right hip and leg.

According to the package insert for hydromorphone hydrochloride (an opiate medication), a precaution warning read, serious, life-threatening, or fatal respiratory depression may occur. Monitor closely, especially upon initiation or following a dose increase.

On continued review of Patient #1's medical record, there was no evidence the patient was placed on a continuous pulse oximetry monitor to monitor her respiratory and oxygenation status. The next set of vital signs were documented at 10:20 a.m., which reported a pulse of 95, respiratory rate of 16, blood pressure of 100/42, and pulse oximetry of 94% on 2 liters of oxygen by nasal cannula. The next pulse oximetry measurement was not documented again until five hours and ten minutes later at 3:30 p.m. and was 80% (reference range 90-100% at high altitude).

This was in contrast to the national standards for safe medication administration practices guidelines provided by the facility which read, frequently monitor respiratory rate, sedation level, and oxygen saturation level by continuous pulse oximetry or exhaled carbon dioxide by continuous capnography to decrease the risk of adverse reactions associated with IV opioid use.

B. Interviews

a. On 12/7/22 at 8:58 a.m., an interview was conducted with registered nurse (RN) #1. RN #1 stated it was not standard on the unit for a patient receiving an intermittent opiate IV medication to be placed on continuous pulse oximetry monitoring, unless it was ordered by a physician or if the nurse assessment of the patient's condition warranted continuous monitoring.

This was in contrast to the national standards for safe medication administration practice guidelines provided by the facility which read, frequently monitor respiratory rate, sedation level, and oxygen saturation level by continuous pulse oximetry or exhaled carbon dioxide by continuous capnography to decrease the risk of adverse reactions associated with IV opioid use.

b. On 12/7/22 at 10:45 a.m., an interview was conducted with the cardiac unit charge RN (Charge) #2. Charge #2 stated it was her practice to place patients on continuous pulse oximetry if the patient was receiving medications that could cause respiratory depression such as morphine or hydromorphone. Charge #2 stated it was her expectation as a charge nurse that nurses on the unit place patients on continuous pulse oximetry monitoring for patients who received opiate IV medications. Charge #2 further stated the risk of not monitoring a patient's pulse oximetry following IV opiate administration or a change in condition was the patient could decline, have respiratory distress or code (a situation where a patient stops breathing and the heart stops beating).

This was in contract to the interview with RN #1 as outlined above.

c. On 12/7/22 at 2:20 p.m., an interview was conducted with unit director (Director) #3. Director #3 stated it was not routine for continuous pulse oximetry to be ordered with IV opiate administration, unless the ordering provider specified continuous pulse oximetry. He further stated he was not aware of a hospital policy or procedure for continuous pulse oximetry monitoring for patients receiving intermittent IV or oral narcotics unless it was ordered by a provider or if the nurse was concerned for a patient's respiratory status. He further stated he was not aware of an existing best practice for routine pulse oximetry monitoring for patients receiving intermittent IV opiates.