Failure to Timely Report Serious Medication Error Resulting in Resident Death
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately, as required by state and federal regulations. Specifically, a resident admitted for respite care received four incorrect doses of morphine sulfate totaling eighty milligrams over a twelve-hour period due to a transcription error. This medication error resulted in the resident becoming lethargic, unresponsive, and experiencing unstable vital signs, ultimately leading to the resident's death. Despite the family's inquiry about administering Narcan to reverse the opioid effects, the facility did not provide this intervention. Facility policy required that all serious adverse events, including medication errors resulting in harm, be reported to the New York State Department of Health (NYS DOH). However, there was no documented evidence that the event or the medication error was reported to the NYS DOH. During interviews, the administrator stated that they did not believe the resident's death was caused by the morphine administration and, after consulting with the executive director and medical director, decided not to report the incident. This failure to report was not in accordance with facility policy or regulatory requirements.