Failure to Administer Scheduled Morphine Due to Lapsed Order Renewal
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and chronic pain, who was prescribed morphine sulfate 15 mg twice daily for pain management, did not receive her scheduled morphine doses for 11 days. The morphine order was a durational order requiring review every 30 days by the Nurse Practitioner. After the Nurse Practitioner’s visit and documentation to continue the morphine, the order was not renewed or sent to the pharmacy, resulting in the medication not being available for administration. The Medication Administration Record (MAR) still showed the morphine as an active order, but no new script was generated, and the pharmacy did not receive a renewal request. During the period without her scheduled morphine, the resident exhibited withdrawal symptoms and was sent to the emergency room for evaluation. Progress notes indicated that the resident experienced vomiting, diarrhea, hypertension, and nonverbal signs of pain, such as grimacing and trembling. The resident’s daughter and hospice staff later became involved, and it was discovered that the morphine order had lapsed. The resident’s condition continued to decline, and she was unable to swallow medications or food in the days leading up to her death. Interviews with facility staff revealed that the lapse in medication administration was due to a failure to renew the morphine order after the Nurse Practitioner’s review. The Assistant Director of Nursing acknowledged that the order should have been written and sent to the pharmacy, and that nurses should have noticed the absence of the order. The Director of Nursing confirmed that the resident experienced opioid withdrawal as a result of not receiving her scheduled morphine. The facility’s policy required care and services to be provided according to the most recent medical orders, which was not followed in this case.