Incorrect Transcription and Under-Dosing of Hospice Morphine Orders
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when hospice morphine orders were incorrectly transcribed and administered at doses lower than prescribed. A cognitively intact resident with chronic respiratory failure with hypoxia, emphysema, and rheumatoid arthritis was admitted on an identified date and had hospice physician orders dated 10/16/25 for 0.25 mL (5 mg) of morphine solution 20 mg per 1 mL to be given by mouth every four hours. The medication administration record for October 2025 showed this order was incorrectly entered as 0.25 mL of morphine solution 20 mg per 5 mL, resulting in a 1 mg dose instead of the ordered 5 mg. The controlled medication count sheet and pharmacy label indicated morphine solution 20 mg per 5 mL was dispensed with a printed dose of 1.25 mL (5 mg), but the dose on the label was altered by hand to 0.25 mL, and the resident received 0.25 mL (1 mg) on 14 occasions on 10/16/25, 10/17/25, and 10/18/25. The DON confirmed the resident was given 1 mg instead of 5 mg on these dates. A second hospice morphine order dated 10/18/25 directed 0.5 mL (10 mg) of morphine solution 20 mg per 1 mL to be administered by mouth every two hours. The October 2025 medication administration record showed this order was incorrectly entered as 0.5 mL of morphine solution 20 mg per 5 mL, resulting in a 2 mg dose instead of the ordered 10 mg. The controlled medication count sheet showed morphine solution 20 mg per 5 mL was dispensed and administered at 0.5 mL (2 mg) per dose on 14 occasions on 10/18/25, 10/19/25, and 10/20/25. A progress note dated 10/20/25 by an RN documented that the resident had been administered incorrect doses of morphine at 2 mg instead of 10 mg, and the DON confirmed the resident received 2 mg instead of 10 mg on those dates. The facility’s Medication Administration policy dated 08/22/22 stated that medications would be administered as ordered by the physician, which was not followed in these instances. This deficiency was investigated under Complaint Number 2647291.
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