Crushed Extended-Release Morphine Administered, Resulting in Harm
Penalty
Summary
A deficiency occurred when a nurse administered a crushed extended-release Morphine Sulfate tablet to a resident, despite the medication being clearly labeled as 'do not crush.' The nurse, who was responsible for medication administration, stated that the resident was known to spit out medications and could become verbally disruptive if pain medication was not given on time. In an effort to ensure the resident received their pain medication, the nurse crushed all of the resident's medications, including the extended-release Morphine, and administered them together. The facility's policy required nurses to check pharmacy labels and follow all instructions, including not crushing medications labeled as such, but this protocol was not followed in this instance. Following administration, the resident was found lethargic in bed by a speech language pathologist, who alerted nursing staff. The resident exhibited decreased responsiveness, decreased respirations, wheezing, and pinpoint pupils. Initial assessments by nursing staff and the physician led to the administration of Solumedrol and Lasix for respiratory symptoms, as the resident had a history of chronic obstructive pulmonary disease and pulmonary hypertension. It was only after further inquiry that the nurse disclosed the error of crushing the extended-release Morphine, prompting the administration of Naloxone to reverse the effects of the opioid overdose. The resident returned to baseline shortly after receiving Naloxone, and the incident was reported to the physician and the resident's representative. Interviews with staff confirmed that the nurse was aware of the 'do not crush' instruction but proceeded due to being in a rush and wanting to address the resident's pain. The facility's policy on narcotic handling and administration was not adhered to, resulting in actual harm to the resident.