IDPH has cited and fined Allure of Zion after the staff mistakenly administered both a Fentanyl patch and Morphine, sending a resident to the ER due to an opiate overdose from the multiple narcotics.
Nursing home residents are in nursing homes for a reason – either they are unable to care for themselves, or they have chronic diseases or conditions which require ongoing care. Regardless of the reason, it is the job of the nursing staff to provide the care, treatment, and services necessary to keep them as healthy and comfortable as possible and to live out their lives with dignity.
The resident at issue was an 88-year-old female admitted to the nursing facility with diagnoses including chronic back pain related to a spinal fracture.
She had been receiving scheduled pain medications including Fentanyl transdermal patches to help manage her pain.
The resident was seen by an outside pain management consulting physician who prescribed her high doses of Morphine sulfate for additional pain control. However, this consulting physician was unaware that his patient was already receiving scheduled Fentanyl patches for pain management from her primary care physician at the nursing facility.
When the resident returned to the facility after her appointment, a nurse entered the Morphine order into the system using the name of the resident’s primary care physician, rather than the actual prescribing consulting physician. The nurse claimed that she did this because the prescribing physician was an outside doctor and she could not select him on the computer.
Critically in this case, the nurse entering the order for Morphine failed to contact and consult with the resident’s primary care physician, whose name she was using for the prescription. The resident subsequently received 11 doses of Morphine sulfate over a four day period in addition to her regularly scheduled Fentanyl patch changes.
To make matters even worse, once the facility became aware of the error, a nurse practitioner was ordered to immediately remove the resident’s Fentanyl patch but was delayed by 24 hours because she was unable to find it on the resident’s body.
Ultimately, the resident was found to be severely lethargic and confused and was sent emergently to the hospital where she was diagnosed with acute encephalopathy and suspected opiate overdose from the multiple narcotics.
Even though this resident had chronic back pain that was difficult to control, she was still entitled to get good care at this nursing home – the same as every other resident. This is a woman who was in great pain, and her life was put in danger due to the failures in care at this nursing home.
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