Unnecessary Administration of Morphine Without Clinical Indication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications, as required by policy and regulation. Specifically, morphine sulfate, a strong opioid, was administered as a routine, standing medication to a resident admitted for respite care, despite no documented clinical evidence of pain or shortness of breath. The medication administration record showed that morphine was given every four hours, with each administration accompanied by a documented pain level of zero. There was no evidence in the clinical documentation to support the need for morphine, and the resident had not previously used morphine at home nor exhibited pain during hospice visits. The resident in question had diagnoses including dementia, end-stage renal disease, and atrial fibrillation, and was rarely understood according to a mental status assessment. The facility’s own policies required that medications be administered according to provider orders and professional standards, and that clinical documentation reflect assessments, identification of problems, and responses to care. Despite these requirements, the administration of morphine was not supported by clinical findings, and a nurse later acknowledged that the dose was excessive and should have been identified as such.