Noted in last month’s report on the incident is the fact that North Ridge Health and Rehabilitation did not have a procedure in place to identify changes in dosages for high risk medication like the oxycodone used in this incident, a violation of MDH procedure.
The resident was originally admitted on a short-term basis for cancer treatment and obstructive pulmonary disease, with their dosage of painkillers changing concentrations frequently.
The night before dying of an overdose, the resident rated their pain as a 10/10–the highest number one can give. The nurse practitioner mistakenly administered 30 milliliters rather than the prescribed 30 milligrams, reporting later that she was “busy with multiple patients.”
The nurse practitioner and the supervisor eventually found the resident unresponsive on the floor of their room. They tried to resuscitate the resident, but were unsuccessful.
As a result, North Ridge will have to re-educate staff and revise policies to prevent similar incidents from happening in the future.