Complaint Investigation Report

Review of R1’s medication records and narcotic log indicated that facility staff were administering R1’s morphine per physician and hospice orders. Review of R1’s routine medications showed that R1 had a prescription for a morphine oral tablet. The morphine oral tablet instructions stated: “Morphine Sulfate Oral Tablet 15MG – Take ½ tablet (7.5MG) by mouth every 4 hours as needed for pain/shortness of breath.”

Record Review for 11/03/2025 showed the following:

· Review of R1’s Narcotic Log shows that R1 was administered morphine at the following times: 5AM, 9:43AM, 11:48AM, 12:10PM, 1:10PM, 4:22PM, 5:43PM,7PM, 9:18PM and 11:25PM.

· R1’s Progress Notes for 11/03/2024 showed that facility staff were communicating with R1’s hospice agency about R1’s increase in pain and were following their instructions. Notes also indicated that Hospice visited R1 on 11/03/2024 to assess them and administer PRN (as needed) morphine.

· At 6:47PM, facility received physician order for “Morphine 15MG oral tablet – Take 1 tablet(s) oral every hour as needed for severe pain; OK to dissolve in water then administer.”

Facility documentation showed that the Facility received this verbal order in the evening after the facility had been giving morphine per hospice instructions.

Hospice Record Review for 11/03/2025 showed that the Hospice Agency conducted visits with R1 at the following times:

· 12PM-2PM; Hospice Notes indicated that R1 was transitioning and that R1 was administered medication

· 5:22PM-8:39PM; Hospice Notes indicated that R1 was administered medication around 3-4PM. Hospice observed R1 to be visibly calm.

Record Review for 11/04/2025 showed the following:

· Review of R1’s Narcotic Log shows that resident was administered morphine at the following times: 9:18AM, 1:57PM, 3:54PM, 5:30PM, 7PM, 8PM, and 9PM

· R1’s Progress Notes showed that R1 was observed to be calm and comfortable at 12:34PM, 2:44PM, 6:55PM, and 6:57PM by facility staff

· At 11:42AM, the facility received verbal orders for the following morphine prescription: 11/4/24; oral concentrate morphine (20MG/ML) administer 0.75ML oral every hour.

Facility documentation indicated that after facility received the new morphine order, they began to administer the new medication order at 3:54PM.