Minnesota Veterans Home Resident Dies from Overdose
Resident at the Minnesota Veterans Home was cited by the MDH. The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type.
Lack Supervision and Monitoring - Resident Fire
The Minnesota Department of Health determined neglect was substantiated. The facility and AP neglected the resident when they failed to follow the facility’s medication administration policy and gave him 20 times the prescribed morphine amount. The resident died.
The Minnesota Department of Health determined neglect was substantiated for AP1 and inconclusive for AP2. AP2 struggled to transcribe the liquid morphine order and asked AP1 for help. While AP2 did contact the on-call provider at least once to clarify the resident’s liquid morphine order, she relied on AP1 for help with the liquid morphine transcription instead of contacting the on-duty nurse supervisor who offered to help with the order. AP1 prepared and administered liquid morphine but failed to follow the facility policy and procedure for medication administration. AP1 also failed to immediately report the medication error to her supervisor and the provider. AP1 also failed to accurately report the medication error to the provider once she realized she gave 100 milligrams (mg) of morphine instead of 5 mg.
According to the MDH a review of the internal investigation records indicated one evening the resident’s family members visited him and reported to staff the resident was struggling to breathe. A staff member checked the resident’s vial signs and raised the head of his bed. He notified AP2, who was the evening shift nurse. Staff members continued to monitor the resident. His oxygen saturation levels were low and other vital signs unstable. AP2 asked the evening nurse supervisor for assistance; they contacted the on-call provider for oxygen and hospital orders. The resident’s family members did not want him sent to the hospital; they returned to the facility and spoke with the on-call provider, requesting comfort cares instead. The provider agreed and gave a phone order for morphine 20 mg/1 milliliter (mL), give 5 mg (0.25mL) every hour PRN (as needed).
The report goes on to state: AP1 logged the medication into the narcotic record and went to prepare the liquid morphine. AP1 drew up five 1 mL full syringes and emptied them into a medication cup. AP1 did not confirm the order with another nurse before giving the liquid morphine to the resident. Investigation records indicated AP1 thought she knew the order, that 5 mg was the same as 5 mL and miscalculated the dose. About 15 or 20 minutes later, AP1 “fixed” the title of the order in the computer because it was wrong. (The morphine brought to the unit was 20 mg/1 mL, not 20 mg/5 mL).
The resident’s death record indicated the cause of death was acute morphine toxicity. In conclusion, the Minnesota Department of Health determined neglect was substantiated for AP1.
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