Tuesday, December 30, 2008

Maplewood Care Cited for Failing to Secure Morphine


50 N. Jane in Elgin
FINED- 2002
Maplewood Care was fined $10,000 for failure to
safely store controlled substances, to maintain a
living environment free of hazards and to immediately
investigate a drug theft.
Responding to a complaint, Department surveyors
learned a female resident took morphine from a nurse's
cart and gave it to a male resident, who later died
from an overdose of the drug. Another resident had
observed the theft and reported it to a nurse, but she
did not investigate the incident or share the
information with a co-worker.
When the nurse realized 14 tablets of morphine were
missing from her cart, she called her supervisor, who
told her to write a note and slip it under her office
door and she would follow up on it in the morning. The
supervisor also told the nurse there was no need to
monitor the resident because she would not overdose.
Nearly seven hours later, the male resident given the
morphine was banging his head on a dresser and was
transported to the emergency room and admitted for a
drug overdose.
The resident had a history of substance abuse and was
admitted to the facility after attempting to overdose
on heroin. His pre-admission screening stated he was
in need of structure and supervision.
Following the incident, the female resident signed
herself out of the facility against medical advice.
She later confessed to stealing morphine and giving it
to the male resident so he could get high. She has
been charged with drug induced homicide, delivery of a
controlled substance and possession of a controlled
Surveyors found the female resident's care plan did
not address an arrest for shoplifting and her suicidal
statements and did not evaluate her medication seeking
The Department-ordered plan of correction required
the facility to review its policies regarding
administering medications and reporting of medication
errors; to ensure medications are locked in a
medication cabinet, room or cart; to take disciplinary
action against any staff failing to report, monitor or
take appropriate action in relation to medication
issues; and to have adequate staff to meet residents'

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