Failure to Administer and Document PRN Morphine per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer and document narcotic medication according to a physician’s order for a resident with dementia and significant behavioral symptoms. The resident had multiple diagnoses including acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention. Assessments and provider notes over time documented moderate to severe cognitive impairment, advanced dementia with behaviors, and near constant yelling, screaming, and agitation that were difficult to redirect. Care plans identified pain, behavior problems, and impaired cognitive function, with interventions that included administering medications as ordered, monitoring for side effects and effectiveness, and using non-pharmacological interventions prior to PRN medications. On a specified date, a physician ordered Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, to give 0.25 ml every 4 hours as needed for pain or shortness of breath. A behavior note from that same date documented that the resident continued to yell throughout the day, that redirection had no effect, and that PRN lorazepam and morphine were administered into the resident’s cheek pocket, pending effectiveness. The Individual Control Drug Record for the resident’s morphine 5 mg pre-filled syringe (0.25 ml/5 mg) showed that two doses were administered that day, one at 10:00 a.m. and another at 12:10 p.m., which was 2 hours and 10 minutes after the first dose, rather than at or after the ordered 4-hour interval. Despite the controlled drug record indicating two morphine doses, the January Medication Administration Record (MAR) contained no evidence that any doses of morphine sulfate oral solution were administered. Progress notes referenced that morphine was given but did not specify how many doses or the exact times of administration. Interviews with nursing staff and the DON confirmed that facility practice and policy require medications to be administered in accordance with prescriber orders, including required time frames, and to be documented on the MAR, with controlled substances also documented on individual controlled substance records. The DON reviewed the morphine order and narcotic reconciliation sheet and stated that administering morphine at 10:00 a.m. and again at 12:10 p.m. did not meet her expectations for following the physician’s order, and staff interviews emphasized that failure to document on the MAR creates a risk of not knowing when a medication was given and of administering another dose too soon. Facility policies on administering medications and controlled substances required that medications be administered as prescribed, that medication errors be documented and reported, and that the individual administering the medication record the date, time, dosage, route, indications, results, and their signature in the medical record or EMAR. The controlled substances policy required accurate individual controlled substance records and reconciliation using MARs and declining inventory records. In this case, the discrepancy between the controlled drug record, the MAR, and the physician’s order, along with incomplete documentation in progress notes, demonstrates that the resident’s narcotic medication was not administered and documented according to the physician’s order and facility policy.
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