Transcription and Dosing Errors for Morphine and Lorazepam
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and administer physician orders for two controlled substances, morphine sulfate concentrate and lorazepam concentrate, resulting in a resident receiving significantly higher doses than ordered. The resident had intact cognition with a BIMS score of 15 and diagnoses including paraplegia, seizure disorder, respiratory failure, malnutrition, and cachexia. Hospice admission orders dated 3/6/26, noted by the facility on 3/7/26, specified morphine sulfate concentrate 20 mg/mL at 0.25 mL (5 mg) by mouth/sublingual every 2 hours as needed for pain or shortness of breath, and lorazepam concentrate 2 mg/mL at 0.25 mL (0.5 mg) by mouth/sublingual every 2 hours as needed for anxiety or restlessness. However, when the orders were entered into the EHR on 3/7/26, the morphine order was transcribed as morphine sulfate concentrate 100 mg/5 mL with instructions to give 2 mL by mouth every 2 hours as needed, and the lorazepam order was transcribed as 0.5 mL every 2 hours as needed, doubling the intended lorazepam dose. The EHR and MAR reflected these incorrect orders, and nursing staff administered medications according to the erroneous entries. On 3/8/26 at 1:11 AM, a nurse (Staff A) documented administering morphine concentrate 100 mg/5 mL, 2 mL, for a reported pain level of 8. The controlled substance log for morphine showed that earlier doses had been logged as 0.25 mL, but at 1:12 AM on 3/8/26, 2 mL was dispensed, reducing the remaining amount from 29.5 mL to 27.5 mL. The resident’s MAR also showed multiple administrations of lorazepam oral concentrate 2 mg/mL at 0.5 mL every 2 hours as needed for anxiety or restlessness, which was twice the ordered 0.25 mL dose, and the facility was unable to locate a controlled substance log for the lorazepam solution. An encounter note later documented that, due to the transcription error, the MAR listed morphine as 2 mL every 2 hours as needed and that the resident received lorazepam 1 mg every 2 hours instead of the intended 0.5 mg. Staff interviews further clarified the actions and inactions that led to the medication errors. Staff F, the MDS Coordinator, stated she entered the morphine and lorazepam orders into the EHR on 3/7/26 and acknowledged that she felt pressured to enter the orders quickly while also working as a floor nurse, and no second nurse double-checked her work. Staff A reported that on the night of the incident, she checked the doctor’s orders and MAR, both of which showed a 2 mL morphine dose, and administered that dose without first checking the controlled substance log. She stated she questioned the high dose given the resident’s recent hospice admission and thin condition but could not locate the original hospice orders. Only after returning to sign out the narcotic in the controlled substance log did she notice that the previous dose had been 0.25 mL, revealing the error. The DON stated that nurses were expected to administer medications as ordered and double-check orders with another nurse, while the Administrator reported there were no written policies and procedures for medication administration, and that the facility followed the general “6 rights” of medication administration.
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