Failure to Discontinue and Appropriately Administer Narcotic Medication Leads to Resident Death
Penalty
Summary
A resident with multiple complex medical conditions, including hypotension, muscle weakness, type 2 diabetes, end stage renal disease, and dependence on dialysis, was readmitted to the facility following a hospital stay. Upon return, the hospital discharge summary included an order to discontinue Hydrocodone-Acetaminophen (Norco) due to concerns about generalized weakness, and this was noted in the resident's nursing notes. However, the Norco order was not discontinued in the facility's electronic medical record (eMAR), and the medication remained available for administration. On the day of the incident, the resident received two doses of Norco within a two-hour period, rather than the prescribed six-hour interval. The first dose was administered by one LVN and documented in the narcotic log but not in the eMAR. The second dose was given by another LVN, who, unaware of the previous administration, provided the medication again when the resident requested pain relief. This resulted in the resident receiving Norco more frequently than ordered. The error was later identified, and the physician was notified, who advised monitoring the resident. Documentation shows the resident became increasingly lethargic, experienced nausea and vomiting, and had a significant decline in responsiveness throughout the day. Despite monitoring and physician notification, the resident's condition continued to deteriorate, with vital signs indicating hypotension and decreased oxygen saturation. The resident was eventually transferred to the hospital due to severe respiratory distress, where she experienced cardiac arrest and expired. Interviews with staff revealed lapses in medication reconciliation, documentation, and adherence to physician orders, as well as failures to properly discontinue medications per hospital discharge instructions and to ensure accurate communication between shifts.