complaint·March 28, 2025

Continued from LIC9099 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. Continued on LIC9099C Continued from LIC9099C Hospice Record Review for 11/04/2025 showed that the Hospice Agency conducted visits with R1 at the following times: · 11:45AM – 12:30PM; Hospice Notes indicated that R1 was observed to be safe and comfortable · 5:30PM to 6:03PM; Hospice Notes indicated that facility staff administered morphine 15 minutes prior to Hospice’s arrival · 9:45PM-10:45PM; Hospice Notes indicated that R1 passed and a narcotic medication count was conducted. “Personal Rights” – Complainant alleged that facility staff argued and verbally harassed R1’s family while R1 was dying. Report received stated that Staff Member 1 (S1) accused R1’s family of physically grabbing and shaking them. Report received stated that Facility’s Executive Director confronted R1’s family about the alleged altercation in front of R1 and did not provide R1 dignity. Interviews conducted with involved parties revealed conflicting statements. Interview conducted with S1 stated that R1’s family grabbed them to make them administer more morphine to R1 even though R1 didn’t look like they were in pain. Interview conducted with Executive Director stated that they were unable to determine if the altercation happened as S1 and the family were the only ones involved. Interview conducted with Witness 1 (W1) denied that the physical altercation occurred, and that the accusation was false. W1 stated that there was a verbal conversation that occurred between themselves, the Facility Executive Director, and S1, but asserted that there had been no physical contact between them and S1 prior to the verbal exchange. Interview conducted with Witness 2 and Witness 3 (W2 and W3), corroborated W1’s statements that there was no physical altercation between W1 and S1 and that there was no yelling or raised voices during the conversation between the family, the Facility’s Executive Director, and facility staff in front of R1. Based on interviews conducted, document review, and observations made, these allegations are Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No Deficiencies Cited during visit. Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.