Physician Failed to Provide Proper Supervision and Accurate Medication Orders
Penalty
Summary
A deficiency was identified when a physician failed to provide proper supervision of medical care for a resident admitted for respite care under hospice services. The physician signed multiple, inconsistent orders for morphine sulfate oral solution with varying concentrations, dosages, and administration instructions within a short period. These orders included conflicting directions such as 5 milliliters every 4 hours, 1 milliliter every 4 hours, and one-time doses, leading to unclear and inaccurate medication instructions. As a result, the resident received 80 milligrams of morphine over a 12-hour period. Pharmacy records documented repeated attempts to clarify the morphine orders with facility staff and the physician due to concerns about dosing and concentration accuracy. Despite these efforts, the orders remained inconsistent, and the pharmacy had to intervene multiple times to clarify and authorize the correct dosages. There was also a request to access Narcan for the resident, but records indicate it was never administered. Interviews revealed that the physician was not typically responsible for respite residents but was asked to handle this resident's orders. The physician admitted to not carefully reviewing the orders, particularly the concentration and dosage, and did not realize the error at the time. After the medication administration issue was discovered, there was no documented evidence that the physician provided any follow-up instructions or care to the resident.