483.25(m)(2) Residents Free of Significant Med Errors
On 10/26/12, a resident on hospice care was mistakenly given twenty times his prescribed dose of morphine sulfate and overdosed and died. The resident had an order for five mg of morphine every six hours. At noon, a nurse gave the resident 100 mg. The nurse realized her error about an hour later when doing documentation. The facility did not have a policy for signing drug accountability records before giving a narcotic medication nor did it have a policy for nurses to have a high alert medication double-checked by another nurse. At 3:00, a hospice nurse administered Narcan to counter the morphine. By 6:00, the resident was unresponsive. He was briefly hospitalized, returned to the facility, and died at 12:55 AM on 10/27/12. His cause of death was morphine intoxication.