F0697

D

Failure to Manage PRN Morphine Orders Safely Resulting in Opiate Toxicity

Salt Lake City, Utah Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pain management in accordance with professional standards of practice for a resident receiving morphine, resulting in opiate toxicity and hospitalization. The resident was admitted with sepsis, obstructive and reflux uropathy, and kidney stones, and had an existing order for immediate-release morphine 7.5 mg every 6 hours as needed for dorsalgia. On admission, medication reconciliation was completed with the family and primary care physician records. Shortly after admission, the resident complained of ongoing pain and requested more morphine than he was receiving. On 1/3, nursing documentation reflected instructions to give 0.5 tablet by mouth every 3 hours for pain and 1 tablet by mouth every 3 hours as needed for pain, and physician orders were entered for morphine sulfate 15 mg, both 0.5 tablet every 3 hours PRN and 1 tablet every 3 hours PRN, creating two active PRN orders for the same opioid at different doses and the same frequency.

The new morphine orders significantly increased the potential daily morphine exposure. Based on the prescribed frequency and dosage, there was a potential for up to 180 mg of morphine to be administered in a 24-hour period, representing an increase of 150 mg per 24 hours from the prior regimen. On 1/5, the physician documented that the resident’s family reported slurred speech, and the physician assessed that there was intermittent dysarthria likely caused by morphine and stated that the morphine should be reduced unless needed for pain levels higher than 4; however, no updated morphine order reflecting this change was found in the medical record. Subsequent nursing notes documented clinical changes, including lethargy, slurred or unclear speech, low oxygen saturations, cough, shortness of breath, and the need for supplemental oxygen and nebulizer treatments. Despite these changes and the physician’s concern about morphine-related dysarthria, the dual PRN morphine orders remained, and there was no documented clarification or consolidation of the opioid orders.

In the days leading up to the resident’s transfer to the hospital, the MAR showed administration of 15 mg morphine tablets with pain scores of 10, 7, and 4, totaling 45 mg in a 24-hour period. On the morning of transfer, nursing documented that the resident appeared lethargic, had cold extremities, and that oxygen saturation could not be obtained despite oxygen being titrated up to 5 L/min, with staff reporting a significant decline compared to the prior day. The resident was transferred to the ED for further evaluation. In the ED, the provider documented that the resident arrived critically ill with hypoxia, slow respiratory rate, confusion, and minimal responsiveness, and noted that the resident had been receiving extra doses above the 0.5 tablet of morphine he was supposed to be getting at least once or twice a day. The ED provider diagnosed opiate toxicity along with hypoxia and sepsis, and the resident responded to naloxone with improvement in respiratory rate, oxygenation, and blood pressure. Interviews with an LPN and the DON revealed that nurses relied heavily on resident request and subjective pain reports to administer morphine, did not consistently question high-frequency opioid orders, and did not obtain provider clarification when two different PRN orders for the same opioid existed, contributing to the unsafe pain management that led to opiate toxicity.

Interviews further clarified the facility’s practices and expectations around opioid administration and order management. The LPN stated that when receiving a physician order, he would repeat it back and then enter it into the record, and that he typically would follow up with a provider if he encountered a morphine order more frequent than every 4–6 hours. However, in this case, he did not follow up with the provider regarding the every-3-hour morphine orders because the resident had been on morphine for some time and appeared to be tolerating it. He also stated that he administered morphine based on resident request, even when pain levels were low, and that on the day of the resident’s decline he gave the higher dose at the resident’s request despite lethargy. The DON stated she expected nurses to use nursing judgment and to contact the physician when there were two different orders for the same opioid, and acknowledged that the morphine order should have been written as a range (0.5 to 1 tablet every 3 hours). The combination of unclarified duplicate PRN morphine orders, lack of documented adjustment after the physician’s concern about morphine-related dysarthria, and reliance on resident preference without adequate clinical reassessment or provider consultation led to excessive morphine dosing and the resident’s opiate toxicity.