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Based on staff interview and record review nursing staff failed to administer a narcotic medication in accordance with physician orders, accepted standards of practice and in accordance with CAH policies and procedures for 1 of 4 applicable patients. ( Patient #1) Findings include:

Patient #1, was admitted to the CAH in 2016. During this continued hospitalization, Patient's #1's health deteriorated. Per the patient's consent and family approval, Patient #1 was placed on Palliative Care. During the provision of end of life care, Patient #1's physician had prescribed pain medication to include: Morphine 5 mg/0.5 ML SC (subcutaneous injection) every 20 minutes for pain and respiratory distress. The Pharmacy provides Morphine in 10 mg (1 ML) predrawn syringes which are stocked and stored in an Omnicell (automated dispensing system) on the Medical;/Surgical unit.

Per CAH Pharmacy Department policy titled: Controlled Substances, effective date June 4, 2015, states "Part V - Administration Waste and Disposal: Any controlled substance packaged in a dose larger than the dose being administered must be wasted immediately before or after administration. Wastage is witnessed and documentation by two individuals, one of which must be licensed. Signature of each individual involved with the wastage of a controlled substance medication is documented electronically....". Per review of the Medication Administration Record (MAR) on 12/14/16 at 1:00 AM Nurse #1 administered 5 mg (.5 ML) of Morphine SC to Patient #1. The nurse followed the required process for waste and disposal of the additional 5 mg prior to administering the prescribed dose of 5 mg. Approximately 2.5 hours later, Patient #1's family reported to Nurse #1 that Patient #1 appeared in pain. After a brief assessment of Patient #1, Nurse #1 obtained another 10 mg syringe of Morphine from the Omni cell, but failed to complete the waste and disposal process by discarding .5 ML (5 mg of Morphine) from the syringe that would be witnessed by another nurse, prior to entering the patient's room. Instead, the nurse went directly to Patient #1's room and administered the full syringe of Morphine 10 mg which was not the prescribed dose.

Per interview on 2/15/16 at 8:20 AM Nurse #1 confirmed s/he was aware of the CAH policy and procedure for waste and disposal of controlled substances but stated it was his/her intent during the administration of the SC Morphine, to only inject 5 mg/.5 ML and was going to stop when the syringe was half empty. Per CAH policy Medication Administration effective 5/1/2015 states: "Before administering a medication, the authorized individual administering the medication completes the following: Verifies that the medication is administered in the correct dose and that the route is appropriate for the medication and patient". The policy also states: " Discard unusable medications per hospital policy". The process of discard should have occurred prior to entering the patient's room, not during the administration of a SC injection. Per review of the Omnicell Transactions by Patient report noted the Morphine 10 mg/1 ML had been removed by Nurse #1 on 12/14/16 at 3:29 AM with no documentation of wasting the medication. Per interview on 4:45 PM on 2/14/17 the Pharmacy Clinical Analysis confirmed s/he had identified the irregularity and reported directly to the Pharmacy manager. Per interview at 9:00 AM on 2/15/17 the Director of Pharmacy also confirmed "....this was a breach in protocol".

Per interview on 2/14/17 at 3:30 PM, the CNO (Chief Nursing Officer) stated s/he had not been informed of the breach in protocol and/or the reported medication administration error. In addition, Nurse #1 stated s/he had not received counseling or involved in a discussion regarding opportunities for improving his/her S.C. medication administration process especially when involving the waste/disposal of a controlled substance (Morphine).

Based on staff interview and record review, the CAH failed to take appropriate action to address an identified deficient practice after receiving a report of a medication error and breach in policy and medication administration protocol. The QA/PI (Quality Assurance/Performance Improvement) program failed to clearly determine the proper remedial action and interventions to ensure the error and nursing practice were analyzed and corrective action initiated to ensure patient safety. Findings include:

Per CAH Pharmacy Department policy titled: Controlled Substances, effective date June 4, 2015, states "Part V - Administration Waste and Disposal: Any controlled substance packaged in a dose larger than the dose being administered must be wasted immediately before or after administration. Wastage is witnessed and documentation by two individuals, one of which must be licensed. Signature of each individual involved with the wastage of a controlled substance medication is documented electronically....". Per review of the Medication Administration Record (MAR) on 12/14/16 at 1:00 AM Nurse #1 administered 5 mg (.5 ML) of Morphine SC to Patient #1. The nurse followed the required process for waste and disposal of the additional 5 mgs of Morphine prior to administering the prescribed dose of 5 mg. Approximately 2.5 hours later, Patient #1's family reported to Nurse #1 that Patient #1 appeared in pain. After a brief assessment of Patient #1, Nurse #1 obtained another 10 mg syringe of Morphine from the Omnicell, but failed to complete the waste and disposal process by discarding .5 ML from the syringe that would be witnessed by another nurse, prior to entering the patient's room. Instead, the nurse went directly to Patient #1's room and administered the full syringe of Morphine 10 mg which was not the prescribed dose.

After Nurse #1 reported the medication error and breach of procedure on 12/14/16, the Occurrence Report was reviewed by the Director of QA/PI and Patient Safety who had also been alerted by the Pharmacy Clinical Analyst of the of the noted event via the Omnicell report. On 12/14/16 at 10:12 AM the Director of QA/PI and Patient Safety reviewed the Occurrence Report with 2 members of nursing services. The error was categorized as an error that reached the patient and monitoring was required to confirm there was no harm to the patient and/or required intervention to preclude harm. From the meeting it was determined Patient #1 did not experience significant harm. It was also noted Morphine was provided in 2 mg, 4 mg and 10 mg dose/syringes and a discussion would be planned with the hospitalist to review Morphine dose orders. The Director for QA/PI and Patient Safety confirmed on 2/14/17 at 4:45 PM s/he failed to discuss the error with the Pharmacist to investigate if there were options in supplying Morphine in alternative predrawn syringes that would not require a nurse to waste half of the dose or administer a full dose in error.

Per interview on 2/15/17 at 9:00 AM, the Director of Pharmacy confirmed Nurse #1 had breached protocol regarding the wasting of .5 cc of Morphine. The Pharmacist further confirmed as of 2/14/17, since the occurrence was brought to his/her attention by the surveyors, the Omnicell will now be stocked with Morphine 5 mg. predrawn syringes. This availability will help eliminate the wasting of medication and will further assure patient safety is being maintained.