Complaint·October 26, 2023

According to complainant, this community uses unlicensed professional staff such as medication technicians (MT) to administer Morphine on hospice resident. According to R1’s physician’s report, R1 is unable to administer own prescription medications, unable to administer own PRN medications, and unable to store own medications. R1 is unable to administer own injections, perform glucose testing, and oxygen. According to R1’s level of care assessment, R1 requires medication assistance up to 2 times a day. R1 is on hospice and currently does not require additional staff involvement. According to R1’s doctor’s orders, on 8/30/2022 Morphine 20 mg/mL liquid concentration (30 mL bottle) was prescribed to R1 per instruction administer 0.5 mL sublingually 2 times per day for pain or shortness of breath this is additional to PRN dose on 6/16/2023. On 8/4/2023, doctor’s orders indicated to discontinue Morphine 20 mg/mL oral concentration administer 0.5 mL 2 times per day. Begin Morphine 20 mg/mL oral concentration, administer 0.5 mL (10mg) sublingually 3 times per day for pain and shortness of breath, this is in addition to PRN dose. On 8/22/2023, Morphine is to be administered every 4 hours for pain and shortness of breath, this is in addition to PRN dose. The Department interviewed and received statements from a total of five (5) Med Techs. Med Techs denies administering Morphine to hospice residents. Interview statement received from Med Techs indicated the facility nurse who is a Licensed Vocational Nurse (LVN), hospice nurse, and residents' family members who are trained administer Morphine to residents who are not capable to assist themselves. Med Techs indicated, if a resident in care is capable of administering own medication without assistance Med Tech is to provide medication to resident and observe to ensure the safety of resident. On 9/18/2023, the Department received interview statement from R1's hospice nurse. Hospice nurse stated resident was prescribed Morphine and family members requested for R1 to be given additional doses for comfort. Hospice Nurse stated did not witness staff that are not skilled professional give morphine to R1. Hospice Nurse stated has worked at Meadow Oaks of Roseville for 6 years and has not witnessed unlicensed professional staff assisting R1 with Morphine. Hospice Nurse indicated Meadows Oaks of Roseville is good at contacting hospice to ensure that any medications such as narcotics are given to resident correctly with permission. Hospice Nurse indicated Meadow Oaks would always call hospice if they had any questions or concern or need recommendations/guidance. The Department finds the allegations to be UNSUBSTANTIATED , meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated. Exit interview conducted. Copy of report provided.