Failure to Timely Report Medication Error Involving Morphine Administration
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including medication errors, were reported to the appropriate authorities within the required timeframes. Specifically, a medication error occurred when an RN administered an incorrect dose of morphine to a male resident with diagnoses of lung cancer and chronic obstructive pulmonary disease. The physician's order specified that the resident should receive 10 mg of morphine sulfate (0.5 ml) by mouth every hour as needed for pain or shortness of breath. However, the RN administered a higher dose than ordered, with documentation and interviews indicating that either 1 ml or 2 ml was given, equating to 20 mg or 40 mg, respectively, instead of the prescribed 10 mg. The discrepancy in the amount administered was confirmed through record reviews, medication administration records, and narcotic count sheets, as well as interviews with the DON and the RN involved. The DON and Administrator both acknowledged the error and discussed it with their corporate team. Despite the facility's policy requiring immediate reporting of such incidents to the State Survey Agency and other authorities, the incident was not reported as required. The Administrator and DON decided, after consultation, that the event did not meet the criteria for reporting, referencing a provider letter, and therefore did not notify the State Survey Agency. The facility's own policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress, and outlines specific procedures for reporting such events within set timeframes. In this case, the failure to report the medication error involving the administration of an incorrect dose of morphine to the resident constituted a violation of both facility policy and regulatory requirements for timely reporting of alleged neglect.