The incident at Sedgwick County Memorial Nursing Home involved Resident #18, who was receiving end-of-life care for uterine cancer, acute kidney failure and high blood pressure. The resident had moderate cognitive impairment and was prescribed morphine for pain and restlessness.
On June 4, 2025, a physician ordered morphine sulfate oral solution at 0.25 ml every four hours as needed. Two days later, the order was changed to 0.25 ml every two hours.
But when LPN #1 entered the new order into the computer system, she typed 2.5 ml instead of 0.25 ml — a tenfold increase in dosage.
The licensed practical nurse approached the director of nursing for help completing the order entry. The director said LPN #1 "did not check off the final check mark to complete an order to be able to push it through and make it an active order."
Instead of verifying the dosage, the director simply checked off the final approval box without double-checking the order against the physician's prescription.
"Every nurse checking off a physician's order should double check that the order matched exactly what was prescribed," the director told federal inspectors during a September 10 complaint investigation.
The computer system generated an automated warning that the order was "outside the recommended dose." The director said she never saw this alert.
Hours later, a night shift nurse noticed the dangerous dosage and brought it to the director's attention. The director confirmed the order was incorrect and said the nurse was going to correct it.
The order was never corrected.
Federal inspectors found the error remained active in the system from June 6 through June 9, when it was finally discontinued. The director said she reviewed controlled substance count sheets and confirmed that nurses had actually given the correct 0.25 ml dose each time, not the 2.5 ml dose listed in the active order.
The resident was discharged on June 7 and died shortly after.
In a separate medication incident, staff failed to notify a physician when a diabetic resident's blood sugar dropped to dangerous levels.
Resident #17's fasting blood sugar measured 53 mg/dl at breakfast on June 21, 2025 — well below the normal range of 70-100 mg/dl. The nurse withheld the resident's scheduled 18-unit Lantus insulin injection but did not contact the physician.
Instead, the nurse added the information to a daily provider note — a non-urgent communication list typically used for routine requests like stool softeners.
"Blood sugars outside of the normal limits should not be put on this list and should instead be called into the provider right away," the director of nursing told inspectors.
By lunch, the resident's blood sugar had risen to 91 mg/dl, within normal limits.
The director said facility policy required immediate notification of the provider, director of nursing, and medical power of attorney whenever a resident experienced a change in condition or when scheduled medications could not be administered.
LPN #2, interviewed separately, said she understood the protocol: "She said she would always notify the provider, the DON and the medical power of attorney right away if a resident experienced a change in condition."
Both violations occurred despite clear facility expectations for medication safety and physician communication.
The morphine error represented a particularly serious breakdown in the medication verification process. Even after the computer system flagged the dangerous dosage and a colleague raised concerns, the incorrect order remained active for three days.
Federal inspectors classified both violations as having caused minimal harm or potential for actual harm, affecting few residents. The inspection was triggered by a complaint filed against the 40-bed facility.
Resident #18 had been admitted for short-term rehabilitation following a hospitalization but required end-of-life care due to the advanced cancer diagnosis. The resident's moderate cognitive impairment, documented with a score of 10 out of 15 on a standardized assessment, made accurate medication administration even more critical.
The facility's medication errors occurred during a vulnerable period for both residents — one dying from cancer, the other managing Type 1 diabetes with neurological complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sedgwick County Memorial Nursing Home from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
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