Montco MH/MR Agency Cited for Overdoses

By Walter F. Roche Jr.


A Montgomery County agency providing services to the disabled has been cited by the state Health Department for dispensing methadone at  dosages of up to four times the amount prescribed by a physician.
In an inspection report recently made public, state inspectors cited two cases in which the wrong dose of methadone was dispensed to patients at Montgomery County MH/MR Emergency Services.
In one of those cases, according to the report, the patient was later discovered unresponsive, with a drastically reduced blood pressure and had to be rushed to a local hospital for emergency treatment.
Officials of the agency, located in Norristown, declined to respond to questions about the ultimate fate of the two patients.
In addition to the overdoses, state inspectors found several other violations of state and federal regulations including the presence of expired drugs and quality assurance deficiencies.
The facility failed to "properly discard expired medicines and supplies," inspectors found.
In the first of the overdoses, the report states that the patient was administered the overdose on Nov. 15 of last year at 5:50 p.m. The mistake was discovered later in the evening prompting the sounding of a crisis alarm.
After a doctor had ordered close monitoring of the patient, staffers discovered at 12:10 a.m. that he was experiencing labored breathing and his skin was discolored. After administering oxygen the patient remained unresponsive and was rushed to a local hospital.
A second patient, according to the report, who was supposed to receive a 40 milligram dose of methadone, was mistakenly given a 175 milligram dose.
Despite that discovery, the inspectors found, the patient was not administered a drug, Naxalone, to counter the effect of the overdose.
"Narcan was not administered even though Narcan was available on the code cart. Everyone is in agreement that Narcan should have been administered," the report states, citing subsequent interviews with agency personnel
Other violations cited included the apparent failure to get patients' consent prior to the administration of psychotropic drugs.
Another finding was the apparent failure to inform patients or their representatives of visitation rights. That was the case in 10 of 12 records reviewed, the report states.
In a plan of correction filed with the state, agency officials promised to implement new procedures to ensure that the proper doses of drugs were administered and steps to be taken in the event of an overdose.
They also promised to establish a monitoring procedure to avert any recurrences.
The inspection, listed as an unannounced federal complaint investigation, took place from Jan.27 to Jan. 28. The report was not made public until the county agency had the opportunity to respond.
According to its latest tax return, the Norristown agency had revenues of $17.1 million and expenses of $18.2 million in the most recent fiscal year.
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