HospitalInspections.org

Based on record review and staff interview, the facility failed to monitor withdrawal symptoms using COWS (Clinical Opiate Withdrawal Scale) protocol for 1 (P [patient]1) out of 3 (P1 - P3) patient reviewed. This deficient practice could lead to patient's withdrawal symptoms not being managed and lead to increased discomfort for patients.

The findings are:

A. Record review of the facility's policy titled, "Opiate/Heroin [substances derived from opium plant] Withdrawal Protocol" dated 04/2022 under "Definition" stated, "Opiate withdrawal syndrome is generally not life threatening. Withdrawals are characterized by hypertension (high blood pressure), tachycardia [increased heart rate], agitation [restless anxiety], tremulousness [shaking or trembling] and anxiety. Onset of withdrawal usually coincides with the time of the next habitual drug dose." Under, "Subjective complaints" stated, "Pt [patient] states withdrawing from ..... (opiate, heroin) - Use of opiate for more than 3 weeks ..." Under "Plan" stated, " ...Tylenol [over the counter pain medication] 650 mg [milligrams] prn [as needed] [every] 6 hours - Complete COWS score 1 [time] daily for 3 days-patient can stay in general population - Reassure - Fluids, electrolyte replacement/rest/clear liquid diet if needed."

B. Record review of P1's medical record for admission on 12/2/2024 revealed the following:

1. Under, "Admission Data" there was a table titled, "Substance Use Withdrawal Symptoms" indicated in this table that P1 was having withdrawal symptoms of nausea, tremors, agitation and irritability.

2. P1's "History [and] Physical" dated 12/3/2024 stated, "[Patient] with a history of depression who was taken to the ER [emergency room] after a suicidal attempt. According to the report the patient took a bunch of pills. Reports stated P1 took 8-10 oxycodone [opiate pain medication] of 20 mg tablets and 320 mg OxyContin [long-acting opiate] tablets while drinking champagne. The patient was given Narcan [opiate reversal medication] by his wife ..."

3. P1's "Psychiatric Progress Note" dated 12/06/2024 at 3:02 AM revealed " ...The patient feeling miserable due to withdrawal symptoms from oxycodone and ongoing pain. He shared that he had been on oxycodone for 15 years before being abruptly discontinued, with his last dose taken on Monday..."

4. P1's medical record revealed the record did not contain a COWS score was performed on P1 during admission. The record did not contain a withdrawal assessment from 12/3/2024 through 12/6/2024.

C. During an interview on 04/15/2025 at 1:20 PM with S(staff)5, clinical, it was explained that the COWS protocol would be implemented for a patient that was on chronic opiate (increasing heavy or frequent use) medications prior to being admitted.

D. During an interview on 04/15/2025 at 3:00 PM with S7, clinical, it was explained that patients coming with a history of opioid abuse should be monitored for withdrawal.