F0684

D

Failure to Monitor Comfort Care and Administer Ordered Hyoscyamine at End of Life

Middletown, Delaware Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess, monitor, and document comfort care for a resident on end-of-life care and failure to follow physician orders for Hyoscyamine Sulfate. The resident had severe cognitive impairment, was on a care plan focused on comfort care, and had diagnoses including severe unspecified dementia with behavioral disturbance, anxiety disorder, and chronic pain. The care plan specified comfort care parameters such as no hospitalization, no lab work, no tube feeding, no IV fluids, and liberalized diet and supplements, with pain assessment and physician contact for uncontrolled pain. From the beginning of November through early November, nursing progress notes and the MAR showed no documented pain or SOB, and pain assessments using a behavioral pain scale consistently recorded a pain level of 0, with no narrative documentation explaining the assessments.

On a later NP visit, the NP documented that the resident had decreased oral intake but no respiratory distress or signs of pain or discomfort, and ordered Hyoscyamine Sulfate sublingual for excessive secretions, lorazepam PRN for agitation/restlessness, and morphine sulfate concentrate PRN for pain/SOB/comfort. Subsequent nursing documentation on the night a PRN morphine dose was given recorded that the resident was in distress and received morphine for comfort, but there was no detailed nursing note describing what type of distress the resident was experiencing. The MAR documented a behavioral pain score of 4/10 at that time, but there was no documentation of how that score was derived using the behavioral assessment, and no corresponding nursing note explaining the assessment. Later that same day, another note documented decreased responsiveness and inability to take PO food/fluids, with the daughter requesting that PRN morphine be made routine; the NP assessed the resident and ordered scheduled sublingual morphine every four hours along with PRN dosing.

The MAR for that day showed the resident continued to be assessed each shift with a pain level of 4, again without documentation of how the behavioral pain score was determined or narrative nursing notes describing the assessment. The NP later changed the Hyoscyamine Sulfate order to 0.125 mg every four hours routinely, and then, after the resident was seen again for increased secretions, the order was increased to 0.25 mg every two hours for increased secretions/end of life. The DON, upon review, noted that the order for Hyoscyamine Sulfate 0.125 mg two tablets every two hours had administrative times marked with Xs and no documentation that the medication was administered, and could not explain why it was not given. Nursing notes from the time the increased Hyoscyamine order was written through the time of the resident’s death did not reflect ongoing assessments or documentation of further signs of impending death. Interviews with nursing staff and leadership confirmed that detailed assessments, alert charting, and documentation of pain behaviors and changes in condition were not completed, that there was no specific comfort care policy, and that staff education on comfort care was limited to general advance directive training.