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Based on policy review, medical record review and interviews, the Registered Nurse (RN) did not evaluate Patient #1's health status/condition after the administration of Narcan and prior to transfer to another facility.

Findings include:

Review of policy " Pain Management " last reviewed 03/26/18 indicates when narcotic antagonists (ex. Narcan) are given (to reverse the effects opiates) , assess for signs of withdrawal such as agitation tremors, sweating, nausea/vomiting. Reassess after 90 minutes for a discharge transfer.

Review of policy " Transfers " effective 02/19/18 indicates the Physician Transfer Certificate and Certificate of Medical Necessity for Ambulance Transfer will be completed. Prior to transfer, a nurse to nurse report is given documenting the time, date and nurse accepting report. Vital signs are rechecked prior to transfer and copies of relevant clinical information will be sent with the patient.

Review of the medical record dated 04/25/18 revealed Patient #1 was being transferred to a higher level of care facility. At 05:29 AM, the last full set of vital signs is entered in the record: pulse (P) 92, respirations (R) 20, blood pressure (BP) 83/49, temperature (T) 97.8 Fahrenheit (F) and oxygen saturation (SpO2) 93%. At 05:55 AM, vital signs are entered in the record: P 91, R 20 and SpO2 93%, but blood pressure is not noted. At 06:00 AM, Staff (X), LPN indicates that while Patient #1 is being transferred to the ambulance stretcher, the patient became very drowsy and giddy, with a change in mentation. Staff (P), Hospitalist was called to the room and Narcan 0.4 mg was ordered and administered, along with a normal saline bolus. Patient #1 was then transferred by ambulance to a higher level of care facility. There is no documentation of a discharge assessment, transfer documentation or post Narcan administration assessment of Patient #1 by an RN.

Interview on 08/27/18 at 08:45 AM with Staff (F), Nurse Educator verified the lack of transfer documentation.

Interview on 08/28/18 at 10:05 AM with Staff (A), Chief Nursing Officer verified the above noted findings.