Philly Patient Gets Double Morphine Dose

By Walter F. Roche Jr.

A patient at a Philadelphia nursing home was given a double dose of morphine for some three weeks, according to an inspection report from the Pennsylvania Department of Health.
The overdose was discovered in an annual inspection of the Maplewood Nursing and Rehabilitation conducted just after Christmas. The report concludes that the 180-bed facility was out of compliance with the standards for participation in the federally funded Medicaid program.
In addition to the multi-week morphine overdose, the report states that the morphine was administered by sublingual pills instead of by feeding tube as prescribed by the physician.
Yet another patient state surveyors found, was administered a second dose of morphine after a two hour interval instead of the three hour limit prescribed.
Overall the report found that the facility's medication error rate was 5.4 percent, exceeding the 5 percent standard.
Other medication errors include a patient getting a double dose of a blood pressure medication and another getting the wrong dose of lidocaine.
Officials of Maplewood filed a plan of correction with the state in which they agreed to re-educate staff on medication and other standards.
The surveyors also cited the home, located in the city's Germantown neighborhood, for unsanitary conditions in food preparation areas.
The facility "did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety," the report states.
Cited was a heavy build up of dust, dirt and "a white powdery substance on the floor."
The inspectors also found that the facility failed to maintain temperature logs for a freezer and allowed a pooling of water on floor surfaces.
In patient rooms, surveyors reported finding dirty conditions.
"The facility failed to provide a clean, comfortable environment for their residents," the report continues.
The home's plan of correction calls for those deficiencies to be eliminated promptly.
In the review of individual patient records, the state found that the facility failed to update records of a patient who had changed her status from "full code" to reflect that she did not want to be intubated.
Other issues include improper handling of linens, and failure to inform a physician of a patient's low blood sugar levels.
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