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:
Significant morphine dose error: An RN administered 0.25 mL (5 mg) of morphine sulfate buccally instead of the ordered 0.1 mL (2 mg) dose to a resident with severe cognitive impairment, Alzheimer’s disease, CAD, and dementia. The RN said she followed the medication box label, while the unit manager confirmed the correct dose was on the EMAR. The resident was assessed afterward and remained unchanged.
An LPN administered Humalog insulin to a resident with stroke, aphasia, and diabetes without priming the insulin pen as required by manufacturer instructions. The LPN dialed the ordered 5-unit dose but did not prime the pen with 2 units before injection, and later stated she was unaware of the need to prime it. The DON confirmed insulin pens should be primed according to the manufacturer's instructions.
A resident with CHF and dysphagia had a medication error when an MA crushed and administered multiple morning meds, including Potassium Chloride ER, despite a provider order that it not be crushed. The facility policy required meds to be given as ordered and prohibited crushing do-not-crush, slow-release, and enteric-coated meds; the record also identified potassium chloride as a high-alert medication.
Two residents experienced significant medication errors when ordered meds were not available or not administered as prescribed. One resident on hospice went more than 24 hours after admission without ordered Morphine for pain and air hunger, while another resident missed multiple doses of a Lidocaine patch and Mirabegron because the meds were out of stock or not obtained from the pharmacy, with the DON confirming the missed doses and unrelieved pain were significant.
A resident with moderately impaired cognition and cerebral amyloid angiopathy had a weekly buprenorphine patch order inaccurately transcribed as Suboxone on the MAR. Staff also applied a new pain patch without removing the old one, leaving two active patches on the resident for several days. The DON stated the admission verification process was not followed and the incident was not investigated.
A resident with DM2 and multiple chronic conditions had an order for daily insulin glargine, but an RN documented that the dose was not given because the medication was unavailable. An LPN stated staff should reorder meds when five doses remain and, if out, notify the provider and pharmacy and use the emergency medication supply system; an RN and the DON confirmed backup insulin was available in a lockbox, and the DON noted there was no documentation explaining the omission.
Significant morphine dose error
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when an RN administered 5 mg of morphine sulfate instead of the prescribed 2 mg dose. The resident had severe cognitive impairment and diagnoses that included Alzheimer's disease, coronary artery disease, and dementia. The physician orders directed morphine sulfate concentrate oral solution 100 mg/5 mL to be given as 2 mg (0.1 mL) buccally every four hours for pain, with a separate PRN order for 5 mg (0.25 mL) buccally every hour as needed for breakthrough pain or shortness of breath. The EMAR showed the resident received the scheduled 2 mg dose at 4:00 p.m. and did not show a PRN 5 mg dose. During observation, RN-B withdrew 0.25 mL of morphine sulfate using the syringe provided with the medication and administered it buccally to the resident, then documented on the narcotic record book that 0.1 mL had been given. RN-B stated she gave 0.25 mL because the medication box label identified 0.25 mL, while RN-A stated the correct dose was 0.1 mL and acknowledged the error after RN-B confirmed the amount administered. The resident was assessed after the error and remained unchanged, with vital signs and condition stable. The DON stated the medication label had been followed instead of the EMAR, and the consultant pharmacist stated the resident could have experienced increased drowsiness from the error.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when it did not follow insulin pen preparation instructions for Resident #8. Resident #8 was admitted with multiple diagnoses including cerebral infarction (stroke), aphasia, and diabetes, and had a physician order for Humalog (Lispro) insulin pen-injector 100 units/ml to be injected subcutaneously at 5 units before meals for type 2 diabetes. During observation on 8/4/26, an LPN removed the Humalog insulin pen from the medication cart and dialed it to the ordered 5 units, but did not prime the pen with 2 units before administering the dose. The insulin was then given to Resident #8. When interviewed shortly afterward, the LPN stated she did not prime the insulin pen and was unaware of the need to do so before administering insulin. The DON stated insulin pens should be primed according to the manufacturer's instructions and had not been.
Significant medication error involving crushing a do-not-crush ER medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Medication Aide crushed and administered medications that included Potassium Chloride ER, despite a physician order stating the medication was to be given by mouth twice daily and not crushed. The resident had diagnoses of chronic diastolic heart failure and dysphagia following a cerebral infarction, and the physician’s orders contained no instruction to crush medications. The facility policy stated medications should be administered as ordered and that medications with do-not-crush instructions, including slow release and enteric coated medications, should not be crushed. During observation, the Medication Aide confirmed they were going to crush all of the resident’s morning medications except Pantoprazole. The aide then placed Clopidogrel, Potassium Chloride ER, Sertraline, and Torsemide into a medication cup, crushed them, added pudding, and fed the mixture to the resident. The record review also identified Potassium Chloride as a high alert medication and cited guidance stating that enteric-coated or extended-release tablets or capsules should not be chewed or crushed.
Significant medication errors from delayed and missed ordered medications
Penalty
Summary
The facility failed to obtain physician-ordered medications in a timely manner, resulting in significant medication errors for two residents. One resident was admitted to the facility on 7/9/26 under hospice care with end-stage heart failure and had an order for Morphine Sulfate concentrate 10 mg sublingually every hour as needed for pain and/or air hunger. The resident did not receive Morphine on the day of admission, and the first documented dose was not given until 7/10/26 at 1:41 p.m., about 26 hours after admission. The MAR documented 26 potential missed PRN doses, and the resident’s family member and an LPN stated the medication was not available when needed and that the resident had signs of pain during that period. A second resident had orders for a Lidocaine external patch once daily for mild pain and Mirabegron ER 25 mg daily for urinary antispasmodic use. The MAR and nursing notes documented that the Lidocaine patch was not administered for multiple days because it was out of stock, with missed applications documented on 7/26, 7/27, 7/29, and 7/30, and 7/28 signed in error as given. The resident stated the missed patches prevented comfortable sleep. The same resident also missed Mirabegron doses on multiple days because the medication was on order from the pharmacy and not available, with documentation showing missed administration on 7/14, 7/15, 7/16, 7/17, 7/19, 7/20, and 7/21, and one date documented as given in error. The DON confirmed the Lidocaine order did not include a dose and acknowledged the resident missed several doses because the facility ran out of the patches. The DON also confirmed the Mirabegron was not supplied as expected and that the convenience box did not contain that medication. The resident and family member stated the missed medications affected pain control, sleep, and urinary urgency, and the DON stated the quantity of missed doses and unrelieved pain equated to significant medication errors.
Medication Order Transcription Error and Duplicate Pain Patch Application
Penalty
Summary
The facility failed to ensure a resident remained free from significant medication errors when admission medication orders were not accurately transcribed to the MAR. The resident was admitted with diagnoses including cerebral amyloid angiopathy, and the comprehensive assessment showed moderately impaired cognition and a need for assistance from one staff member with ADLs. The hospital discharge orders included a weekly buprenorphine transdermal patch, but the July 2026 MAR listed the medication as a weekly Suboxone transdermal patch instead. Staff later stated the wrong medication name was entered because Suboxone was believed to be the same medication as buprenorphine, and the admission body check was not completed to determine whether a transdermal patch was already present. The resident representative reported that facility staff applied a new pain patch without removing the old one, leaving two active patches on the resident for three days. Staff later confirmed one patch was on the right shoulder and another on the left shoulder, and the older patch was then removed. The DON stated the facility’s medication error process included staff interviews, physician notification, alert charting, and monitoring for high-alert medications, but also stated the incident was not investigated and no medication error report was completed. The DON further stated the admission process required a three-step verification of orders, and that process was not followed for this resident.
Missed Insulin Dose Due to Medication Unavailability
Penalty
Summary
A resident with type 2 diabetes mellitus, chronic diastolic heart failure, chronic respiratory failure, and obesity had a physician order for Insulin Glargine Solostar 300 units/mL, 50 units subcutaneously once daily. On 3/20/26 at 11:19 AM, an RN documented that the insulin was not administered because the medication was unavailable. During interviews on 7/30/26, an LPN stated that medications should be reordered through the eMAR when five doses remain and that if a medication is completely out, staff must immediately notify the provider and pharmacy and use the emergency medication supply system. An RN confirmed that backup insulin was available in a lockbox in the third-floor refrigerator and that staff should not run out of insulin. The DON also confirmed the backup insulin location and the pharmacy restocking alert system, and stated there was no documentation in the progress notes or TAR explaining the omission; because she was not employed at the facility at the time, the exact reason for the unavailable medication and omitted dose remained unknown.
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