BRUCEVILLE TERRACE - D/P SNF OF METHODIST HOSP.
8151 BRUCEVILLE ROAD, SACRAMENTO, CA 95823
Citation Number: 030003486
Citation Date: 1/23/2007
Violation Date: 10/17/2006
Class: AA
Penalty: $ 100000.00

72311- Nursing Service. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.

72311- Nursing Service. (a) Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient.

72313 - Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed.

72523 - Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.

On 10/24/06 an unannounced visit was made to the facility to investigate self-report number CA00096697 regarding patient care and services. A subsequent visit was conducted on 10/27/06.

The Department determined that the facility failed to: 1. Administer Patient A's morphine (a pain medication) intravenous (IV) infusion in accordance with the physician's order that stated a maximum infusion dose of 10 mg/hr. On 10/17/06, Patient A received between 120 mg and 150 mg of morphine over a 2 hour, 10 minute period. 2. Monitor Patient A's response to the morphine infusion as required by the 10/17/06 care plan problem for comfort care. Nursing staff did not document continuing assessment or monitoring of Patient A's response to the morphine infusion during the 2 hour, 10 minute infusion period. 3. Document administration of the morphine infusion on the medication administration record (MAR) as required by the March 2006 Guidelines for Medication Administration policy and procedure. Document the morphine infusion medication error in Patient A's medical record as required by the facility's Medication Error policy and procedure. 4. Promptly notify Patient A's attending physician of the morphine infusion medication error. The medication error occurred on 10/17/06 and Patient A's attending physician was not notified of the medication error until 10/20/06, 4 days after occurrence.

These failures resulted in Patient A receiving between 120 mg and 150 mg of morphine by IV infusion over a 2 hour, 10 minute period on 10/17/06 (from 12:30 p.m. to 2:40 p.m.). The morphine dose was excessive and not in accordance with the physician's orders. Nursing staff did not ensure accurate morphine administration or documentation and did not assess Patient A's response to the morphine during the infusion period. On 10/17/06 at 2:40 p.m., Patient A was found dead.

A 10/24/06 review of Patient A's medical record revealed a 74 year old male admitted to the facility from 09/12/06 to 10/17/06 with diagnoses that included end-stage (terminal) chronic obstructive pulmonary disease (COPD). The medical record documented that Patient A did not want cardiopulmonary resuscitation (CPR) or transfer to the acute care hospital.

The 09/24/06 Minimum Data Set (MDS, an assessment tool that describes a Patient's physical and psychosocial functioning) described that Patient A had some difficulty with decision-making, required total assistance with activities of daily living (eating, dressing, toileting) and had occasional (less frequently than daily), excruciating pain.

Patient A's care plan included a 09/12/06 problem for "ineffective breathing patterns related to COPD" with interventions that included to "Administer medications, respiratory treatments, and oxygen as ordered." Patient A also had a 10/17/06 problem for "...diagnosis of terminal illness - comfort measures only, potential for pain due to terminal diagnosis of COPD" with interventions that included administration of "pain medication prn (as needed) and monitor effectiveness - call MD (physician)."

The October 2006 Physician's pain medication orders included: MS Contin (morphine sustained release pill) 30 mg by mouth every 12 hr for relief of respiratory distress (ordered 10/07/06) and "Morphine Sulfate 100 mg/100 ml NS IV drip (infusion), begin at 1 mg/hr, may titrate by 1 mg every hour prn respiratory distress, comfort, max (maximum) of 10 mg/hr (ordered 10/17/06)."

Review of the Controlled Drug Record for Patient A's morphine 100 mg/100 ml NS IV solution showed a total of two bags of solution received from the pharmacy on 10/17/06. The record showed that Registered Nurse (RN) 1 documented signing out the first bag on 10/17/06 at 12:30 p.m. and the second bag on 10/17/06 at 1:30 p.m.

On 10/17/06, RN 1 documented (no time noted) on an Interdisciplinary (ID) Progress Note that Patient A refused to take breakfast, was not able to swallow lunch and the physician was notified. RN 1 documented that she received an order for "morphine 1 mg/hr may titrate by 1 mg (every hour) prn..." RN 1 documented that at 12:30 p.m., Patient A was alert and responsive with respirations even and labored, the morphine was started and "will continue to monitor." At 2:40 p.m., RN 1 documented that Patient A was found without respirations and the physician and responsible party were notified.

A 10/24/06 review of the labeling on Patient A's two empty morphine infusion solution bags (preserved by the Director of Nursing ([DON]) showed the following instructions for administration: "Infuse IV at 1mg/hr, may titrate by 1mg every hour as needed for respiratory distress, pt. comfort (max 10mg/hr)...morphine 100mg/100ml NS"

Review of Patient A's October 2006 MAR showed the physician's order for the morphine infusion with checkboxes for hourly documentation of the morphine dose/rate. The MAR for the morphine infusion was blank, indicating that RN 1 did not document administration of the morphine infusion to Patient A on the MAR.

Patient A's medical record did not contain documentation of a RN assessment or monitoring of Patient A's response to the morphine infusion from 10/17/06 at 12:30 p.m. when RN 1 started administration of the morphine infusion, to 10/17/06 at 2:40 p.m., when Patient A was found expired (a 2 hour, 10 minute period). Furthermore, Patient A's medical record did not contain a description of any unusual occurrence, including a medication error, related to the administration of the morphine infusion to Patient A.

A 10/24/06 review of the facility's policies and procedures for medication distribution and documentation revealed: * A 06/01/91 Drug Distribution policy and procedure that described, in part, that "Medications will be administered by licensed personnel as ordered by the prescriber." * A March 2006 Nursing Services: Guidelines for Medication Administration that described, in part, under the heading of "Accuracy" that "The right (medication) dose is given." The policy described under the heading of "Documentation" that "The time and dose of the drug administered is recorded on the MAR." * An undated Medication Errors policy and procedure that described, in part, that a medication error is "any preventable event that may cause or lead to inappropriate medication use while the medication is in the control of the health care professional. Such events may be related to medication... administration, documentation..." The policy described that types of medication errors include "Improper (medication) dose resulting in overdosage..." and "Document the following in the Patient's health record...description of the medication error."

RN 1 stated during a 10/27/06, 9:15 a.m. interview that during the day shift on 10/17/06, Patient A was unable to swallow the MS Contin and a supervisor (a RN) called Physician 1 and obtained an order for a morphine drip (infusion). RN 1 said that she had not administered a morphine drip before and asked RN 2 (a more experienced nurse) for assistance. RN 1 explained to RN 2 that the bag was a morphine drip. RN 2 looked at the bag label but not the physician's order and instructed RN 1 to "run (the morphine drip) at 100 ml/hr."

RN 1 stated that on 10/17/06 at 12:30 p.m., RN 1 administered the morphine infusion (hung the bag) to Patient A, who was "gasping for air" and in discomfort. RN 1 said that she set the morphine IV infusion rate (via an electronic infusion pump) at 100 ml/hr. RN 1 then asked RN 2 to check the infusion rate. RN 2 went into Patient A's room and then came out and gave RN 1 the "thumbs up" sign. RN 1 thought that since RN 2 had checked the infusion rate and gave the thumbs up, the morphine was infusing as ordered.

RN 1 said that she went to lunch and upon returning to check on Patient A, found the first bag of morphine empty. RN 1 signed out the second bag of morphine at 1:30 p.m. and administered the bag to Patient A. At the time of hanging the second bag, RN 1 said she was "uncomfortable" with the 100 ml/hr rate and decreased the rate to 20 ml/hr. RN 1 said that Patient A, at 1:30 p.m., had labored (difficulty) breathing. At about 2:30 p.m., RN 1 said she gave change of shift report to RN 3. RN 3 said to RN 1 that the morphine rate may not be correct and both RN 1 and RN 3 went to Patient A's room where they found the patient dead.

RN 1 stated that she notified Physician 1 and Patient A's wife of the patient's expiration. RN 1 said she realized that the morphine infusion dose/rate was a medication error but did not report the error to Physician 1 or the patient's wife or document the medication error in Patient A's medical record as required by the Medication Errors policy and procedure. In addition, RN 1 said that she did not document administration of the two morphine infusion bags on Patient A's October 2006 MAR.

RN 1 said that administering the morphine infusion at 100 ml per hour resulted in Patient A receiving 100 mg of morphine over a 1 hour period from 12:30 p.m. to 1:30 p.m. RN 1 confirmed that when the second bag of morphine infusion was administered at 20 ml/hr., Patient A received morphine at a 20 mg/hr rate. RN 1 acknowledged that the 10/17/06 physician's order for the morphine infusion showed a maximum dose of 10 mg per hour of morphine.

RN 1 was asked about the steps a RN should take to ensure accurate administration of medications and said that a RN should check that the medication is given to the right patient, right route, right time and at the correct dose. RN 1 acknowledged that Patient A received an excessive dose of morphine that was not administered per the physician's orders.

RN 2 stated during a 10/24/06, 12:50 p.m. interview that she was working the day shift on 10/17/06 with RN 1. RN 2 said that on 10/17/06, RN 1, towards the end of the day shift, said to RN 2 that it was her first time "infusing." RN 2 did not recall RN 1 saying that she was infusing a morphine drip. Thinking that RN 1 was referring to infusion of an antibiotic, RN 2 said to RN 1 to infuse at 100 ml/hr. RN 1 later asked RN 2 to check Patient A's infusion pump to see if "she had did it right." RN 2 said that she went to Patient A's room and checked the pump which showed a 100 ml/hr infusion rate. RN 2 stated that she did not check the IV solution bag to identify the medication or prescribed dose. RN 2 acknowledged that she should have checked Patient A's physician's orders and the medication bag to ensure medication administration accuracy (as required by the Nursing Services: Guidelines for Medication Administration policy and procedure).

RN 3 stated during a 10/27/06, 10:35 a.m. interview that she was working the evening shift on 10/17/06. RN 3 stated at about 2:30 p.m., she was performing the change of shift narcotic count and noted that one bag of morphine was signed out for Patient A. RN 3 said she asked RN 1 about the second bag and RN 1 said that she had given (administered) the second bag at 1:30 p.m.

At about 2:35 p.m., RN 3 said that RN 1 told her that she was not sure of Patient A's morphine infusion rate; RN 1 said "It seems too fast" and RN 1 said that she lowered the rate to 20 ml/hr. RN 3 said that she and RN 1 went to Patient A's room and observed that the morphine infusion rate was 20 ml/hr. At 2:40 p.m., Patient A did not have any pulse or respiration. RN 3 said she recalled looking at the room clock to note Patient A's time of death. RN 3 observed that the morphine infusion bag was about half empty. RN 3 acknowledged that Patient A received an excessive dose of morphine that constituted a "significant" medication error.

Patient A received between 120 mg and 150 mg of morphine administered over a 2 hour, 10 minute period. If administered as per the physician's order, "Morphine Sulfate 100 mg/100 ml NS IV drip (infusion), begin at 1 mg/hr, may titrate by 1 mg every hour prn respiratory distress, comfort, max (maximum) of 10 mg/hr (ordered 10/17/06)"; the maximum morphine dose over the same period would be approximately 4 mg. Patient A received an excessive dose of morphine equaling between 116 mg to 146 mg more than ordered by the physician (over 29 times the ordered dose rate).

Physician 1 stated during a 10/26/06, 10:15 a.m. interview that he was Patient A's attending physician, and Patient A had terminal, end-stage COPD with a comfort care plan of care. Physician 1 said that on 10/17/06, Patient A was not able to take oral pain medications effectively, his condition was deteriorating and was started on a morphine IV infusion per the patient's family request. Physician 1 confirmed that on 10/17/06 he gave the order for the morphine infusion that included a 10 mg/hr maximum dose.

Physician 1 acknowledged that Patient A received in excess of 100 mg of morphine on 10/17/06 between 12:30 p.m. and time of death. Physician 1 agreed that the administered dose of morphine was excessive and a medication error. Physician 1 said that he was not notified of the medication error until staff called him on Friday, 10/20/06 (4 days after the medication error occurrence on 10/17/06).

Physician 1 said that Patient A was "imminently terminal" before the morphine infusion was started but that an excessive dose of morphine can cause respiratory depression and may have "hastened" Patient A's death.

The facility's Pharmacy Consultant (PC) confirmed during a 10/27/06, 10:05 a.m. interview that Patient A's 10/17/06 physician's order for the morphine infusion, if administered at a 100 ml/hr rate equated delivery of 100 mg/hr of morphine. The PC agreed that Patient A received in excess of 100 mg of morphine on 10/17/06 from 12:30 p.m. until time of death and said that the morphine dose was excessive and a significant medication error. The PC agreed that the RN error in administering Patient A's morphine infusion was not in accordance with the facility's March 2006 Nursing Services: Guidelines for Medication Administration that describes steps to ensure medication accuracy, including ensuring that the right dose is given.

The DON agreed during a 10/27/06, 11:05 a.m. interview that Patient A received in excess of 100 mg of morphine on 10/17/06 between 12:30 p.m. and the time of death. The DON acknowledged that RN 1 did not administer the morphine infusion as per the physician's 10/17/06 order and as required by the Drug Distribution policy and procedure. Furthermore, the DON agreed that RN staff did not: * Follow steps to ensure accurate administration of Patient A's morphine infusion including ensuring the right infusion dose. * Document administration of the morphine infusion on Patient A's MAR. * Document in Patient A's medical record, physician notification of the morphine medication error as required by the Medication Error policy and procedure. * Document assessment or monitoring of Patient A's response to the morphine infusion as required by the comfort care plan problem.

The Department determined that the facility failed to: 1. Administer Patient A's morphine (a pain medication) intravenous (IV) infusion in accordance with the physician's order that stated a maximum infusion dose of 10 mg/hr. On 10/17/06, Patient A received between 120 mg and 150 mg of morphine over a 2 hour, 10 minute period. 2. Monitor Patient A's response to the morphine infusion as required by the 10/17/06 care plan problem for comfort care. Nursing staff did not document continuing assessment or monitoring of Patient A's response to the morphine infusion during the 2 hour, 10 minute infusion period. 3. Document administration of the morphine infusion on the medication administration record (MAR) as required by the March 2006 Guidelines for Medication Administration policy and procedure. Document the morphine infusion medication error in Patient A's medical record as required by the facility's Medication Error policy and procedure. 4. Promptly notify Patient A's attending physician of the morphine infusion medication error. The medication error occurred on 10/17/06 and Patient A's attending physician was not notified of the medication error until 10/20/06, 4 days after occurrence.

These violations presented imminent danger to the patient and were a direct proximate cause of the death of Patient A.