complaint·November 7, 2023

R1 was initially prescribed Morphine .25 mg/ml as needed for pain. Per hospice notes dated 01/05/2022 and 01/07/2022, resident is unable to make needs known and unable to verbalize pain. Facility LVN's were the ones providing the Morphine to the resident as needed. Witness indicates expressing to staff that R1 was unable to verbalize pain and would request R1 be given the medication. Resident could be observed to be in pain by moaning and grimacing. Hospice prescribed a new order of Morphine in the morning on 01/26/2022 for Morphine 0.5 mg/ml, three times daily, routine. Per hospice notes, nurse arrived in the evening of 01/26/2022 to ensure medication was being administered. Resident is observed to be in pain with no Morphine administered. Hospice notes stated that Staff 1 (S1) indicated the staff had not received an order even as there was an order for Morphine as needed, still standing. Hospice nurse administered the medication to the resident. Hospice nurse attempted to educate S1 regarding medication orders and the purpose of hospice care and the staff was "Not receptive." The next day, 01/27/2022, Hospice nurse arrived to the facility to discover facility staff had failed to administer routine or as needed Morphine, again, despite education and medication orders. Hospice nurse administered the medication during the visit and resident was put on comfort measures that day. Resident passed away on 01/29/2022. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director Ayala and a copy of this report was provided.