F0760

D

Failure to Implement Hospice-Recommended End-of-Life Comfort Medication Orders

Middletown, Rhode Island Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident was free from significant medication errors when hospice-recommended end-of-life comfort medication orders were not implemented. The resident, admitted with diagnoses including Alzheimer's disease, hypertension, and atherosclerotic heart disease, was declining and experiencing increased pain and agitation. A hospice RN assessed the resident in the late afternoon and recommended scheduling Morphine concentrate 5 mg every 2 hours and Ativan (Lorazepam Intensol) 0.5 mg every 2 hours, with PRN orders for both medications every hour for breakthrough pain or agitation. At the time of the resident's death, the MAR still reflected prior orders: Lorazepam Intensol 0.25 ml three times daily, Lorazepam Intensol 0.25 ml every 2 hours PRN for restlessness, and Morphine sulfate 0.25 ml every 2 hours PRN for pain greater than 4, with no evidence that the hospice recommendations had been entered or activated.

The RN on duty stated she texted the new hospice recommendations to the resident's physician, and the surveyor verified a text message indicating new hospice recommendations for scheduled and PRN every 1-hour Ativan and Morphine, to which the physician responded "ok." However, the RN could not provide evidence that the orders for scheduled every-2-hour Morphine and Ativan or the hourly PRN orders were ever implemented. The resident's physician indicated that the nurse should have implemented the hospice recommendations after they were approved. MAR review showed the last dose of Ativan was given at 10:00 PM the night before death and the last dose of Morphine at 2:13 PM the previous afternoon, approximately 8 and 16 hours, respectively, before the resident died at 6:17 AM. The DON acknowledged that the resident did not receive Ativan and Morphine as ordered for end-of-life comfort.