Failure to Ensure Dignified and Equal Care Due to Unquestioned Medication Error for Hospice Resident
Penalty
Summary
The facility failed to ensure equal access to quality care and uphold the rights to dignity and self-determination for a resident receiving hospice services. Staff did not question, assess, or respond appropriately to a significant medication error involving the administration of morphine sulfate. The resident, admitted for respite care with diagnoses including dementia, end-stage renal disease, and atrial fibrillation, had not previously received morphine at home according to both hospice records and statements from health care proxies. Despite this, staff administered morphine as ordered without verifying the appropriateness of the dose or the resident's prior exposure to the medication. Licensed Practical Nurses involved in the resident's care reported that they did not question the morphine order or dosage because the resident was on hospice, even though one nurse later acknowledged the dose seemed excessive. The medication was administered multiple times, and concerns about the dosage were only raised after several doses had already been given. Registered nursing staff also deferred to the hospice status of the resident, focusing on comfort rather than reassessing the medication order or the resident's response to the drug. Family members observed that the resident was unresponsive and could not be awakened after the administration of morphine. When concerns were raised about the resident's condition and the possibility of using Narcan to reverse opioid effects, facility staff and an unnamed physician advised against it, stating it was not safe or effective at that time. The lack of timely assessment and intervention following the medication error compromised the resident's right to dignified and appropriate care, as required by facility policy and federal regulations.