Failure to Administer Ordered Morphine for Hospice Resident in Distress
Penalty
Summary
The deficiency involves the facility’s failure to protect a hospice resident with COPD exacerbation and respiratory failure from neglect when ordered morphine for pain and shortness of breath was not administered. The resident had a physician’s order for morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. Progress notes documented that the resident experienced COPD exacerbation, groaning, difficulty breathing, thirst, distress, rapid breathing, anxiety, and difficulty swallowing. The medication administration record showed the resident received one dose of morphine on 11/6/25 at 8:38 PM, with no further doses given that day despite ongoing symptoms. Multiple staff interviews indicated that the LPN assigned to the resident’s care refused to administer the ordered morphine despite reports from other staff that the resident was screaming, anxious, short of breath, disoriented, and exhibiting terminal agitation behaviors such as pulling off clothes, screaming, and crying. Staff reported that the LPN stated she did not want to depress the resident’s breathing and would not listen to other staff, would not call hospice or the physician, and refused to give the medication cart keys to another LPN who attempted to medicate the resident per orders. CNAs and another LPN described the resident as having a very bad night, being in pain and distress the whole shift, and stated they believed the resident was being neglected. The hospice care manager reported hospice staff were frustrated with medication administration not being done as ordered and confirmed that morphine was appropriate for shortness of breath and could benefit the resident by slowing rapid breathing. The LPN later stated she did not remember if she gave the medication and did not provide further documentation or explanation.
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