A nursing home in northwestern Minnesota has been cited for neglect in the case of a resident with a severe cognitive disability who died after nurses gave him 10 times his prescribed dose of morphine.

The Mahnomen Health Center, an acute-care hospital with a 42-bed nursing home, has been found responsible in the case for failing to transcribe the man’s medications accurately, according to a state investigation report released Tuesday.

The man, whose name was not disclosed, died one hour and 45 minutes after the medication error, state investigators found.

“The facility failed to have adequate policies in place to ensure medications were transcribed accurately and then administered correctly,” according to the report from the Minnesota Department of Health, which regulates nursing homes, assisted-living centers and other elder-care facilities.

The patient was suffering from chronic kidney disease and had been transferred to hospice care at Mahnomen Health Center the day before the medication error occurred. Upon arrival, his physician added an order of morphine sulfate, delivered through a syringe placed against the inside of his cheek, every hour. However, the order was incorrectly transcribed onto the patient’s record, causing the patient to receive a dose 10 times larger than the amount prescribed.

Hospital staff members referred questions to chief executive Dale Kruger, who did not return calls.

A nurse at the facility told investigators that he had questioned another nurse about the size of the dosage, but was told it was correct. The error was detected about 15 minutes after the dose was given. Employees notified the patient’s family and they asked staff members to administer a drug, Narcan, to block the effects of the morphine. Meanwhile, the patient’s breathing had decreased to a mere two breaths per minute. The family requested another dose of Narcan, but the patient died before staff members could return from the hospital with the drug.

The resident’s primary physician said a large dose of morphine would have contributed to the death, according to the state report.

The medication error death comes amid a sharp increase in cases of abuse and neglect at state-licensed nursing homes. The number of maltreatment complaints from nursing home patients and their families has doubled over the past five years, from 588 complaints in 2011 to 1,177 in the 2015 fiscal year, according to the Health Department.

 

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