Failure to Administer and Document Morphine Doses as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cancer, bone fracture, and Parkinson's disease did not receive morphine as ordered for pain management over a period of nine days. The resident was cognitively intact and had a care plan that required administration of pain medications as ordered by the physician. The physician's orders specified morphine 15 mg, to be given as half a tablet (7.5 mg) three times a day, with an as-needed order also in place. However, discrepancies were found between the Medication Administration Record (MAR) and the Narcotic Record, with the total doses documented as administered not matching the doses signed out, and missing signatures for narcotic waste. The morphine card count was correct, but documentation and administration practices were inconsistent. Interviews with medication aides (MAs) and licensed vocational nurses (LVNs) revealed that doses were sometimes documented as given at times when they were not actually administered, and that staff did not always follow procedures for wasting the unused half-tablet of morphine. One MA admitted to documenting a dose as given at a scheduled time even though it was administered later, and another MA reported saving the half-tablet in the medication cart instead of destroying it with a witness, as required. Staff also reported confusion about whether doses had already been administered, leading to further discrepancies in documentation. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that staff were not consistently following procedures for narcotic destruction and documentation, and that the correct dose and records had not been updated promptly after the physician's order was changed. Facility policy required accurate reconciliation of physician orders upon admission, proper accounting for controlled medications, and destruction of unused narcotics with a witness. Despite these policies, the failure to administer morphine as ordered, improper documentation, and lack of adherence to controlled medication procedures resulted in the resident missing doses of pain medication. The resident was unaware of the missed doses and reported a pain level of 6 at the time of interview.