F0755

D

Failure to Accurately Document and Reconcile Liquid Morphine for a Resident

Winslow, Arizona Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately record, store, and reconcile a controlled medication, Morphine Sulfate, for one resident with multiple serious diagnoses including senile degeneration of the brain, dementia, cellulitis, nutritional deficiency, psychotic disturbance, anxiety, pneumonia, and chronic pain. The resident had a physician’s order for Morphine solution 20 mg/5 mL (4 mg/mL), 0.25 mL by mouth every 4 hours as needed for pain, initiated in early March. The resident’s care plan identified end-of-life related pain and required prompt response to pain complaints, administration of pain medication as ordered, assessment of pain characteristics and effectiveness of pain medication, monitoring for side effects, and ensuring pain medication was available when needed. The individual controlled substance record for this resident’s Morphine showed a steady countdown in 0.25 mL increments until an entry on July 31, where 25.25 mL remained, followed by an undated entry showing 20 mL remaining before the next dated entry on August 5. The record then continued with a steady countdown until mid-January, when a 0.25 mL dose was documented with 10.25 mL remaining.

During an observation of the narcotic count process, surveyors noted that two nurses verified narcotic counts by one reading the name and written amount from the narcotics book while the other visually checked the medication. Staff interviews revealed that the facility’s process for administering liquid narcotics included checking the eMAR, preparing the medication, signing it out in the narcotics book, rechecking the eMAR, and then administering the dose. However, an RN reported that during a narcotics check prior to a shift, the narcotic count for this resident’s Morphine was not correct, with about 7 mL missing compared to what was documented. The RN stated that the Morphine bottles supplied by hospice did not have measurement markings on the side, making it impossible to visually determine the exact amount remaining and requiring staff to estimate by “eyeballing” the bottle. She also reported that there had been incidents where nursing staff failed to document removal of Morphine in the narcotics book or failed to check it out in the eMAR, and vice versa.

The DON confirmed that the facility’s medication administration process required verification of the five rights, review of orders, appropriate timing, and documentation on both the eMAR and narcotics sheet, and that this process applied to liquid Morphine as well. She explained that Morphine from the primary pharmacy arrived in bottles with clear panels and increment markings, along with a paper narcotics log, while hospice-supplied Morphine bottles had clear panels but no increment markings. The DON stated that before the incident, nurses would look at the hospice bottles without fully measuring or quantifying the remaining amount. She reported that on a date in late January, staff noticed that the amount in the Morphine bottle did not match the 10.25 mL recorded on the narcotics log for a mid-January administration. When the remaining medication was drawn into a syringe, it was confirmed that it was not 10.25 mL. The DON also noted that staff were using in-house leur-lock syringes instead of the syringe provided with the hospice medication, which could trap or leak liquid in the lower space of the syringe. The facility’s Medication Management policy required narcotics to be kept in a separate locked drawer and accounted for at each shift change, and medications to be stored in their original labeled containers, but the documented discrepancies and missing Morphine demonstrated that these requirements were not consistently met for this resident’s controlled medication.

The DON further stated that the lack of measurement markings on hospice Morphine bottles made it hard to know how much medication was left and that prior to the incident, staff relied on visual estimation rather than precise measurement. She indicated that when she examined the bottle at eye level, it did not appear to contain the amount documented on the narcotics log, and that pulling the remaining medication into a syringe confirmed the discrepancy. She also acknowledged that using in-house syringes with a different tip design than the hospice-provided syringe created a risk of medication remaining in or leaking from the syringe. The DON stated that this situation could pose a risk that residents might miss medication doses, remain in pain, or not receive medication at all. Overall, the findings showed that the facility did not ensure accurate documentation, measurement, and reconciliation of a controlled substance for this resident, in contrast to its own policy and stated procedures for narcotic management.