Failure to Verify Morphine Concentration Leads to Repeated Overdose
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to Morphine administration. The resident was cognitively intact with a BIMS score of 12 and had diagnoses including Diabetes Mellitus, Anxiety Disorder, and COPD. The MDS and care plan identified the resident as dependent on staff for many ADLs and at risk for discomfort related to the end-of-life process, with directions to administer pain medications as ordered if non-medication interventions were ineffective and to evaluate the effectiveness of pain-relieving medications. A physician order specified Morphine Sulfate oral solution 10 mg/5 ml, with instructions to give 1 ml by mouth every 4 hours as needed for air hunger, which equated to a 2 mg dose per administration. Despite this order, the Morphine dispensed and received from the pharmacy was of a different concentration and labeling than ordered. The label on the plastic bag indicated a 100 ml bottle of Morphine Sulfate with directions to give 1 ml (2 mg) every 4 hours as needed, while the box label documented 30 ml Morphine Sulfate solution 100 mg per 5 ml (20 mg/ml) with directions to take 1 ml (20 mg total) every 4 hours as needed for severe pain or air hunger. The Controlled Medication Utilization Record also reflected Morphine 20 mg/ml with instructions to take 1 ml (20 mg) every 4 hours as needed. The EMAR, however, showed an order for Morphine Sulfate 10 mg/5 ml, give 1 ml every 4 hours as needed for pain or air hunger, and doses were signed out as given on three occasions. This discrepancy between the ordered concentration (10 mg/5 ml) and the dispensed concentration (20 mg/ml) was not identified or reconciled by nursing staff prior to administration. Nursing staff actions and inactions contributed directly to the medication error. One LPN reported that when she administered Morphine, she looked at the EMAR but did not look at the dosage on the EMAR or check the concentration; she focused only on the instruction to give 1 ml and relied on the bottle label and narcotic sheet, both of which indicated 1 ml equaled 20 mg. She acknowledged that she did not verify the dose against the original order and that the EMAR did not specify the milligram amount, only the volume. An RN who later administered two additional doses stated she checked the narcotic sheet and PCC, saw Morphine 20 mg/ml with instructions to give 1 ml every 4 hours as needed, and administered 20 mg doses without reviewing the original order or questioning the size of the dose. Another RN acknowledged that the process used when the Morphine was delivered did not follow the usual practice of two nurses comparing the bottle and paperwork against the order. The DON confirmed that the original order was for Morphine 10 mg per 5 ml, give 1 ml (2 mg), and stated that the nurses failed to double check the dose against the order even though it was correctly transcribed on the MAR. The pharmacist later confirmed that the pharmacy had received an order for Morphine 10 mg per 5 ml but dispensed Morphine 100 mg per 5 ml (20 mg/ml) due to an initial data entry error, and the ARNP verified that the order she wrote was for 10 mg per 5 ml, 1 ml (2 mg) every 4 hours PRN, with a maximum of 12 mg per day. The sequence of events shows that the resident received three doses of Morphine at 20 mg per dose instead of the ordered 2 mg per dose. Progress notes documented that the resident had labored breathing and air hunger, with Morphine given to assist with breathing and pain, and that the resident remained lethargic with decreased urine output and minimal intake. A subsequent note indicated that the Morphine was discontinued while awaiting a new order, and later that day the resident was found without pulse or respirations. Interviews with staff and the ARNP and primary care physician confirmed that the wrong concentration and dose of Morphine had been dispensed and administered, and that the resident had been in a declining state with end-stage COPD and hospice care. The facility’s policies required nurses to compare received medications with the MAR and clarify discrepancies before administration, and to review the five rights during medication administration, but these steps were not effectively carried out in this case, resulting in the significant medication error. Additional documentation from the facility’s incident report and staff interviews further detailed the breakdown in verification processes. Staff described that the pharmacy label and narcotic record both reflected the higher concentration and dose, and that one nurse sought informal reassurance from hospital nurses using discharge paperwork rather than verifying against the original written order or contacting the prescriber or pharmacy for clarification. Another nurse acknowledged that she did not question whether 20 mg was an appropriate dose for the resident and did not know what a normal dose would be for a hospice resident. The night shift supervisor stated he advised use of Morphine for air hunger based on the resident’s labored respirations but was unaware at the time that the wrong dose was being administered. The ARNP later discovered the discrepancy when another LPN questioned the medication, and the pharmacist confirmed that the pharmacy had dispensed the wrong concentration based on an incorrect drug selection during order entry. These combined actions and omissions by the pharmacy and nursing staff led to the administration of Morphine at ten times the ordered dose on three occasions, constituting the significant medication error identified by surveyors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure residents were free from significant medication errors when one resident drank coffee containing another resident’s medications. The DON stated medications should always be observed during administration, but a CMA said they did not watch the resident take the meds and gave them in coffee without observing the resident drink it. The physician was notified and reviewed the medications involved.
Unattended Medication Left at Resident Bedside: A resident with severe cognitive impairment had a medication cup containing four tablets left unattended on the bedside table. An LPN stated she placed the medications there while getting juice and admitted this was against facility policy. RN and DON confirmed medications should not be left unattended at the bedside and that the action violated the facility’s medication administration P&P.
Missed Hydroxyurea Doses on Admission: A resident with thrombocytopenia, chronic myeloproliferative disease, and CML did not receive ordered Hydroxyurea on admission. The hospital discharge order called for Hydroxyurea 500 mg every other day, but the med was not entered promptly, pharmacy delivery was delayed, and the MAR showed the first documented dose was not given until several days later. The family member reported the resident missed his chemotherapy med for three days, and staff interviews showed uncertainty about who completed the admission med review and when the order was obtained.
Medication Error Caused Severe Bradycardia and Hospital Transfer: A severely cognitively impaired resident with sinus bradycardia received his scheduled AM meds and then was mistakenly given another resident's meds, including metoprolol succinate ER, amlodipine, tamsulosin, and donepezil. He became lethargic with HR in the 30s to 40s and BP 90/60, was sent to the hospital, and was diagnosed with severe symptomatic bradycardia, hypotension, and progression to complete heart block requiring epinephrine, atropine, and a dual-chamber pacemaker.
Missed Antiseizure Medication Doses: A resident with epilepsy and other significant diagnoses did not receive ordered Phenytoin doses because the bubble pack was empty and the medication was unavailable in the cart. An LPN reported missed doses, another LPN said she faxed the pharmacy more than once but did not follow up, and the DON acknowledged 19 missed doses. The pharmacist said only a 3-day supply had been delivered and the facility had not provided required physician clarification before the refill was issued. The resident later had seizure activity and was transferred to the hospital for further evaluation.
A facility failed to administer multiple ordered medications for three residents. One resident with seizure disorder, hypotension, and colon cancer missed repeated doses of seizure meds, midodrine, Depakote, and an antibiotic; a second resident with seizure disorder, diabetes, and HTN missed repeated doses of lamotrigine, levetiracetam ER, and pregabalin; and a third resident with diabetes and cellulitis missed ordered sliding-scale insulin doses, with blood glucose not monitored at the missed times. An LVN stated meds should be given as ordered, and the ADON and pharmacy consultant acknowledged the missed administrations.
Medication Administration Error
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents reviewed for medication administration. A policy stated medications are to be administered at the time they are prepared and the resident is to be observed taking them. The record showed that one resident drank coffee containing medications that belonged to another resident, and the medication administration record showed that the other resident received Rexulti 2 mg, buspirone HCl 10 mg, and alprazolam 0.5 mg. The DON stated medications should always be observed during administration to ensure the resident takes all of the medication and to prevent another resident from taking them. CMA #2 stated they did not watch the resident take the medications and gave the medications in coffee without observing the resident drink it. The physician stated they were notified that one resident had taken medications belonging to another resident and ordered the evening medications held, vital signs monitored, and assessments completed.
Unattended Medication Left at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were secured and administered according to its medication administration policy for one sampled resident. Resident 3 had diagnoses including encephalopathy and senile degeneration of the brain, and the MDS dated May 6, 2026, showed a BIMS score of 00, indicating severe cognitive impairment. During observation on July 2, 2026, a medication cup containing four tablets was found unattended on Resident 3’s bedside table in the resident’s room. When asked, Resident 3 stated she did not know whether the medication belonged to her and appeared confused. During the same observation, RN 1 confirmed the four tablets were left unattended on the bedside table and stated that it was against facility protocol to leave medication unattended at the bedside. RN 1 stated the medications likely had been left there by LVN 1 and should have remained under LVN 1’s direct supervision until administered. LVN 1 stated the tablets belonged to Resident 3 and admitted she had placed them on the bedside table while she went to obtain juice for the resident, acknowledging that leaving the medications unattended was a mistake and was not consistent with the facility’s medication administration policy. The DON reviewed the policy, which stated that medications are to remain secured when the medication nurse or aide is out of sight, and confirmed that leaving medications unattended on a bedside table violated facility policy and the expected standard of practice.
Missed Hydroxyurea Doses on Admission
Penalty
Summary
The facility failed to ensure that a resident with thrombocytopenia, chronic myeloproliferative disease, and chronic myeloid leukemia received Hydroxyurea as ordered upon admission. The resident was admitted with a hospital discharge instruction to start Hydroxyurea 500 mg, 1 capsule by mouth every other day, beginning on 4/24/26. A physician progress note on 4/24/26 documented that the resident was taking Hydroxyurea 500 mg once daily and stated that the medication list was reviewed and reconciled with the patient. The resident’s medication order was not entered into the facility’s order summary until 4/27/26, when a physician order for Hydroxyurea 500 mg every 48 hours was documented. That same evening, an RN documented that the oncologist called with the order, noted the order was already in place, and recorded that pharmacy was called to deliver the medication. The RN also documented that the resident’s family member said she could go to her pharmacy to get the medication, then later documented that the pharmacy reported the Hydroxyurea would be delivered that night and that the family member could not obtain it from the pharmacy. The MAR showed the resident received Hydroxyurea 500 mg by mouth on 4/29/26, and documentation indicated the medication was not administered on 4/27/26. In a telephone interview, the family member stated the resident missed his chemotherapy medication for three days while in the facility and that they gave him the medication after bringing the issue to staff’s attention. Interviews with nursing and administrative staff indicated uncertainty about who completed the medication review on admission and that the facility expected family members to bring chemotherapy medications from home, with the medication not being ordered from the pharmacy until after the oncologist was contacted.
Medication Error Resulted in Severe Bradycardia and Hospitalization
Penalty
Summary
The facility failed to prevent a significant medication error involving a severely cognitively impaired resident with diagnoses including Alzheimer's disease, sinus bradycardia, hypertension, diabetes, depression, and psychotic disorder with hallucinations. On the morning of the event, a Medication Aide administered the resident's scheduled medications, which included propranolol ER, quetiapine, donepezil, metformin ER, and citalopram. The aide then returned to the medication cart, prepared another resident's medications, and later gave those medications to the same resident in error. The medications mistakenly given to the resident included metoprolol succinate ER, tamsulosin, amlodipine, and donepezil, which were prescribed for another resident. Approximately 30 minutes later, the Medication Aide realized the error and reported it to the nurse. The resident was assessed and found to be lethargic with a heart rate in the 40s that dropped into the high 30s and a blood pressure of 90/60. EMS was contacted and transported the resident to the hospital for evaluation. Hospital records documented severe symptomatic bradycardia and hypotension secondary to an unintentional medication overdose with beta blockers and amlodipine. The resident's ECG progressed from sinus bradycardia with second-degree AV block to complete heart block, and he required epinephrine infusion and atropine with limited response. He later underwent implantation of a dual-chamber pacemaker and returned to the facility after hospitalization. Interviews with the Medication Aide, nurse, NP, pharmacist, and Medical Director confirmed that the resident received both his own morning medications and another resident's medications, and that the medication error was associated with the resident's decline in heart rate and blood pressure.
Missed Antiseizure Medication Doses
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including epilepsy, hemiplegia, hemiparesis, and hypertension received Phenytoin as ordered. The physician’s order required Phenytoin 100 mg by mouth at 9:00 AM, 1:00 PM, and 5:00 PM for seizures, but the Medication Administration Record showed multiple missed doses from June 7 through June 17, 2026, totaling 19 doses. During interview, an LVN stated one dose was not given because the bubble pack was empty, and another LVN stated the medication was not in the bubble pack for a couple of days and that she faxed the order to the pharmacy more than once because the medication was not available in the medication cart. The DON reviewed the MAR and acknowledged the medication was not administered for eight days, totaling 19 doses, and stated medications must be available for residents and that the pharmacy is contacted immediately when they are not. The pharmacist stated only a three-day supply had been delivered and that the facility did not provide required clarification from the physician before June 18, 2026, so the pharmacy did not issue a refill until that date. The resident’s clinical record also documented seizure activity on June 17, 2026, with two petite mal seizures and a blood pressure of 162/111, after which the physician ordered transfer to the hospital for further evaluation.
Repeated Missed Medication Administrations
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for three sampled residents. Resident 1 had diagnoses including colon cancer, muscle weakness, seizure disorder, and hypotension, and the MDS indicated the resident’s cognition was not intact and the resident was unable to make decisions. The physician orders included Keppra, lacosamide, Depakote, midodrine, and metronidazole, but the MAR showed multiple missed doses of each medication across May 2026, including repeated missed evening doses of seizure medications, missed midodrine doses, missed Depakote doses, and missed metronidazole doses. Resident 2 had diagnoses including muscle weakness, seizure disorder, hypertension, diabetes, and a history of falls, and the MDS indicated cognition was intact. The physician orders included lamotrigine, levetiracetam ER, and pregabalin, but the MAR showed multiple missed doses of all three medications in May and June 2026. The missed doses included repeated omissions of the seizure medications and pregabalin at scheduled administration times. Resident 3 had diagnoses including cellulitis of both lower limbs, diabetes, and hypertension, and the MDS indicated cognition was intact. The physician order included insulin aspart by sliding scale before meals and at bedtime, but the MAR showed that blood glucose was not monitored and the insulin order was not administered on multiple occasions in June 2026. During interviews, an LVN stated medications should be administered as ordered, and the ADON acknowledged that the residents had multiple medications not administered as ordered. The pharmacy consultant stated antibiotics should be given as scheduled and completed, missing seizure medications increase the chance of seizure episodes, and the facility should follow physician orders for medication administration.
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