A devastating medical error at the Minnesota Veterans Home resulted in a resident's death after receiving 20 times the prescribed dose of morphine during end-of-life care.

According to KARE 11, the Minnesota Department of Health investigation determined the incident, which occurred during an overnight shift, was a result of maltreatment by a staff member. The investigation report, filed in late July, revealed that the employee failed to follow proper medical protocols and professional standards.

The resident, who suffered from multiple conditions including stroke, diabetes, dementia, and atrial fibrillation, required comprehensive care from the facility's staff. The patient needed assistance with daily activities such as bathing, dressing, and grooming, while also relying on a wheelchair for mobility.

Critical Decision Made During Night Shift

The situation escalated when the patient began experiencing breathing difficulties and unstable vital signs during the night. Instead of hospital transfer, the family opted for comfort care, leading to a morphine prescription of 20 milligrams to be administered in 5-milligram hourly doses.

The nurse on duty administered 100 milligrams of morphine without seeking confirmation from another healthcare professional. By the time the error was discovered, it was too late to administer Narcan, a medication that could have potentially reversed the overdose effects.

A nursing supervisor later informed the family about the medication error, leaving them in a state of shock and emotional distress. The resident's death certificate officially listed acute morphine toxicity as the cause of death.

Investigation Reveals Professional Negligence

During subsequent interviews, the employee acknowledged her failure to consult with the nursing supervisor regarding the morphine order. The staff member expressed remorse and disbelief over the incident, which led to severe consequences.

The Minnesota Department of Health's investigation concluded that the employee had failed to maintain professional standards and exercise proper judgment. The investigation also determined that the staff member did not act in the best interest of the vulnerable adult under her care.

The employee is no longer working at the Minnesota Veterans Home following the incident. The facility has since implemented stricter protocols to prevent similar incidents from occurring in the future.

Minnesota Department Takes Corrective Action

The Minnesota Department of Veterans Affairs issued a statement confirming their full cooperation with the state investigation. They emphasized their commitment to using the findings to enhance their care protocols and resident safety measures.

The department acknowledged that any harm to residents is unacceptable and pledged to maintain focus on improving care quality. They have initiated a comprehensive review of their medication administration procedures and staff training programs.

The incident has prompted discussions about the need for enhanced safety measures in veterans' care facilities. The case has become a catalyst for policy changes and increased oversight in medication management procedures.

Impact Extends Beyond Single Incident

The tragic event has highlighted the critical importance of following established medical protocols in healthcare facilities. The case has drawn attention to the challenges faced by healthcare workers during night shifts and the necessity for proper supervision.

The family continues to grapple with the devastating loss of their loved one due to a preventable medical error. Their experience has sparked conversations about accountability and safety measures in veterans' care facilities across Minnesota.

This incident serves as a sobering reminder of the vital importance of maintaining strict medical protocols and professional standards in healthcare settings. The Minnesota Veterans Home case has become a turning point for implementing more rigorous safety measures and oversight in veterans' care facilities throughout the state.