Failure to Notify Hospice and Resident Representative of Significant Medication Error
Penalty
Summary
A significant medication error occurred involving a resident who was admitted for respite care and received four incorrect doses of morphine sulfate totaling 80 milligrams over a twelve-hour period. Despite facility policies and a service agreement with hospice requiring immediate notification of significant changes or medication errors to hospice and the resident's representative, there was no documented evidence that hospice was notified of the error. Additionally, the resident's representative was not informed of the medication error until nearly three weeks later, as indicated by a progress note documenting a meeting with the family to review the events surrounding the resident's passing. Interviews revealed that after the error was discovered, the responsible RN discontinued the incorrect order, notified the physician, and obtained a new order, but did not inform the Director of Nursing or administration at that time. The administrator was not present during the incident and only became aware after receiving a voicemail from the resident's representative. The family had attempted to contact the DON but did not receive a response. The medical director confirmed that the family was not immediately informed about the medication error.