Failure to Monitor and Document Respiratory Rate Before Morphine Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order requiring respiratory rate (RR) monitoring prior to administering morphine sulfate to a resident. The facility’s medication administration policy states that medications are to be administered in accordance with written physician orders. The resident was admitted under hospice care with diagnoses including vascular dementia, anemia, physical debility, and COPD. Physician orders for morphine sulfate oral solution were entered on multiple dates with instructions to administer specific doses for severe pain and to hold the medication if the RR was less than 12. These orders applied both when the medication was ordered as needed and when it was ordered routinely every eight hours. Review of the resident’s Order Summary Reports and Medication Administration Records showed that morphine sulfate was administered on multiple days under each of the active orders, but there was no documented evidence that the resident’s RR was obtained prior to any administration. During interviews and concurrent record reviews, a licensed nurse stated that the current order required checking the RR before giving morphine and acknowledged there was no documentation of the RR. The Assistant DON also stated that RR must be documented prior to morphine administration and acknowledged the missing documentation. The DON later confirmed that the RR should have been included and monitored per the physician’s instructions and acknowledged the lack of documentation that this was done.
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