HospitalInspections.org

The Condition of Participation: Nursing Services

Findings included:

Based on record review and interviews the Hospital failed to ensure Morphine Sulfate (an opioid pain medication) was administered correctly and per Hospital policy, resulting in an adverse drug event requiring naloxone (a medication used for the emergent treatment of known or suspected over dose) administration for one patient, Patient #10, out of a sample of 10 patients.


Cross reference TAG: A-0405.

Based on record review and interviews the Hospital failed to ensure Morphine Sulfate (an opioid pain medication) was administered correctly and per Hospital policy, resulting in an adverse drug event requiring naloxone (a medication used for the emergent treatment of known or suspected over dose) administration for one patient, Patient #10, out of a sample of 10 patients.

Findings include:

The Hospital Policy titled, "Medication Use (Ordering, Transcription and Administration of Medications)", revision date January 2024 included the following:

-All inpatients will have a completed computer-generated Medication Reconciliation Record.

-Medication reconciliation must occur when a patient is transferred from one level of care to another.

-Verify the five rights of medication, (right patient, medication, dose, route and frequency) administration against the e-MAR.

Patient #10 was admitted to the Hospital on 1/30/24 with diagnoses including, dementia, diabetes, hypertension, and a history of falls.

Review of Patient #10 ' s medical record indicated Patient #10 presented to the Hospital ' s Emergency Department (ED) from an Assisted Living Memory Unity with a concern for increased falls. Medical record further indicated Patient #10 had multiple falls with a head strike and daughter brought Patient #10 into the ED for care. Medical records also indicated Patient #10 was disenrolled from hospice services on 1/30/24 by Patient #10 ' s daughter, who was requesting workup for traumatic injuries and an evaluation for a Urinary Tract Infection (UTI). A medication reconciliation was completed on admission on 1/30/24 at 4:35 P.M. and included Morphine 20 milligrams (mgs) by mouth (PO) every 4 hours and Lorazepam 0.5 mgs tab PO every 4 hours and indicated medications were obtained from a list from outside facility. A Physician ordered Patient #10 ' s medication per the medication reconciliation per Hospital protocol. A medication list from the outside facility indicated morphine 20mg/ml concentrate 0.25-0.5 milliliters (mls) orally every 4 hours as needed (PRN) for pain/air hunger. The list also indicated Lorazepam 0.5 mgs tablet PO every 4 hours PRN for anxiety/agitation.

Review of Patient #10 ' s Medication Administration Report indicated on 1/30/24 at 11:47 P.M., Patient # 10 received 20 mgs of Morphine PO and Lorazepam 0.5 mgs. Further review indicated on 1/31/24 at 3:09 A.M., Patient #10 received 20 mgs of Morphine PO. On 1/31/24 at 8:10 A.M., indicated Patient #10 received Naloxone 2 mgs via nostril.

Review of the medication/fluid event incident report dated 2/1/24 indicated on 12/30/24 Patient #10 ' s home medications were updated by a Registered Nurse (RN) #2 and Morphine was entered as 20 mgs PO every 4 hours. The medications were reconciled, ordered, and verified. Two doses of morphine were administered, and the patient required Narcan (an emergency medication used to reverse opioid) on 1/31/24 at 8:47 A.M. The incident report failed to indicate corrective actions were fully investigated or implemented.

During an interview on 7/11/24 at 12:01 P.M., Emergency Department (ED) Nurse Manager said the medication error event occurred due to a home medication list that was incorrectly put into the medical record. The ED Nurse Manager recalled Patient #10 ' s medication error incident but does not have any documentation to support that staff education was implemented following the adverse event.

During an interview on 7/11/24 at 2:48 P.M., RN #2 said she input Patient #10 ' s medications into the electronic medical record incorrectly and said she was new to the process of medication reconciliation. RN #2 said she remembers some discussion about the incident but received no written education/follow up.