F0760

D

Significant Medication Errors Involving Opioid and Potassium Dosing

Perry, Iowa Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer medications as ordered by physicians, resulting in significant medication errors for two residents. One resident with intact cognition, diabetes mellitus, arthritis, CVA with hemiparesis, and chronic pain was ordered Morphine Sulfate ER 15 mg three times daily for chronic pain and Morphine Sulfate 15 mg every 12 hours PRN. The facility received notice from the pharmacy that the Morphine ER was not on hand due to a manufacturer delay, and the on-call provider directed staff to continue giving the PRN Morphine until the ER formulation was available. However, the nurse on duty did not place the Morphine ER order on hold, so it continued to appear on the MAR. On the day of the error, the CMA administered Morphine IR at 7:50 AM, 10:22 AM, and 1:00 PM, while signing off the doses as Morphine ER on the MAR, based on her understanding that the IR was being used in place of the ER and on the resident’s statement that she could take it every 8 hours like the ER medication.

The clinical record lacked a narcotic utilization record for Morphine ER on the date of the error, while the narcotic record showed three doses of Morphine IR given in a short time frame. The February MAR documented Morphine ER as given that day at AM and noon, and Morphine IR as given at 7:49 AM, creating a discrepancy between what was documented and what was actually administered. The resident later reported that the CMA had given too many doses of Morphine IR in a short period, describing confusion about the day and feeling “so messed up,” and stated that the error was traumatic. The CMA acknowledged giving the Morphine IR too close together and not following the physician’s order, and reported that the nurse had instructed her to give the IR in place of the ER and was not helpful. Another nurse reported discovering from the narcotic record that three doses of Morphine IR had been given in a short period and notified facility leadership.

For the second resident, who had intact cognition and diagnoses including hypertension, kidney disease, hyponatremia, and edema, the MAR contained two Potassium Chloride ER orders: 20 mEq once daily every other day for hypokalemia and 40 mEq once daily every other day for diuretic use. On one occasion, the resident reported receiving only 20 mEq instead of the ordered 40 mEq, stating she was supposed to get four potassium pills but only received two. A grievance and an incident report documented that the nurse had given only 20 mEq instead of 40 mEq, and that the medication card still contained the dose for that day. The nurse reported being confused by having separate medication cards for the alternating 20 mEq and 40 mEq days. The March MAR, however, showed Potassium 40 mEq signed off as administered on that date, indicating a discrepancy between the documented administration and the actual dose given. Facility policy required staff to administer medications as prescribed and to verify the right resident, medication, dosage, time, and route by checking the label three times before administration.