A Taranaki rest home has been found to have failed its duties to provide qualified staff when a patient died after he was given five times his maximum prescribed dose of morphine.
The Health and Disability Commissioner, HDC, launched an investigation after receiving a complaint from the patients son about the services provided at New Plymouths Molly Ryan Lifecare and Retirement Village.
Deputy Health and Disability Commissioner Rose Wall released a report into the 2018 incident on Monday.
Wall recommended two of the nurses involved write letters of apology to the family of the deceased and made a number of recommendations to avoid such an incident happening again.
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Wall said the patient, a man in his 80s, had multiple existing health conditions and had been prescribed morphine for worsening pain.
During one shift a nurse drew up 2.5ml of subcutaneous morphine solution without checking the prescribed route of administration or calculating the dose, after being told the man appeared to be distressed.
The subcutaneous morphine solution administered to the man contained 25mg of morphine, which exceeded the maximum quantity prescribed by a factor of five, the report said.
The solution was administered orally in the morning, in the afternoon it was reported the man was unresponsive, and he died that night.
While medication competency was a requirement before staff were allowed to administer stock-controlled medications such as morphine, neither the registered nurse nor the two caregivers on duty had met the medication competency requirements set out in the Medication Management Policy.
Wall found Molly Ryan failed to provide the man with service from suitably qualified/skilled and/or experienced service providers.
The service provider had also failed to ensure the systems in place were sufficiently robust to guarantee that all staff complied with the Medication Management Policy.
Medication-competency training had not been fully completed by staff with responsibility for medication management before they were rostered on duty and, as such, the staff concerned were not supported to administer medication safely, and were not suitably skilled to deliver the standard of care required.
She found the administering nurse in breach of the Code of Health and Disability Services Consumer Rights for administering medication without checking the appropriate route or calculating the appropriate dosage.
The recommendations included auditing every shift at the village for a period of one month to ascertain whether at least two medication-competent staff members were on duty on each shift.
This also included reporting to the HDC any medication errors for a period of three consecutive months, together with a root cause analysis and mitigation strategies to reduce the likelihood of any such error occurring again.