Legacy Park Health and Rehab: Morphine Dosing Error - TN
The resident, identified in inspection records only as Resident 7, was prescribed Morphine Sulfate 20 mg per 5 ml, to be given in 0.25 ml doses, meaning each dose should have delivered 1 mg of the drug. Instead, a licensed practical nurse transcribed the order using a different concentration, one that made each 0.25 ml dose equal to 5 mg. The resident received doses at 8:00 PM on August 9, August 10, and August 11, 2024, each five times stronger than what the physician ordered.
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See the Derila PillowThe transcription error originated the night before, on August 8. A facility nurse removed morphine from the emergency narcotic box and faxed paperwork to the pharmacy. The Director of Nursing told inspectors that the fax contained the correct concentration but an incorrect frequency. What ended up in the electronic medical record was wrong on concentration.
The pharmacy received those faxed forms and a separate order from the hospice agency. Pharmacist A, as he is identified in the inspection report, conducted a Medical Record Review on August 9 and listed no recommendations. He did not flag the morphine order.
When inspectors interviewed Pharmacist A on February 27, he explained how the system worked. The pharmacy enters orders into a profile, which then populates a web-based program that contract pharmacists use to complete their reviews. The profile the pharmacy had entered listed Morphine 100 mg per 5 ml, give 0.25 ml or 5 mg every two hours as needed. What the medical record showed was Morphine 20 mg per 5 ml, give 0.25 ml every two hours on a routine schedule. Those are two different concentrations. Pharmacist A told inspectors he should have caught it.
He didn't question the shift from as-needed dosing to a scheduled routine, he said, because that kind of change is not unusual for a hospice patient. He confirmed he missed the concentration discrepancy entirely.
He also told inspectors he wasn't certain whether anyone rechecks the medical record once the facility sends the pharmacy a signed prescription, or whether the profile gets updated at that point. Once his initial admission review is complete, he said, his portion is finished. He doesn't see subsequent orders.
That gap, between what the pharmacy's profile said, what the medical record said, and what the physician actually ordered, went unresolved for three nights while Resident 7 received morphine doses that were five times too strong.
The Director of Nursing confirmed to inspectors that LPN A entered the incorrect concentration into the electronic medical record for two separate morphine orders: one for pain and shortness of breath, dosed every two hours, and one at bedtime for pain. Both were wrong in the same direction, the same error repeated twice in the same record.
Federal inspectors classified the level of harm as minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects regulatory categories, not a clinical assessment of what five milligrams of morphine versus one milligram means for a hospice patient over three nights.
Morphine dosing in hospice care is calibrated carefully. The drug is used to manage pain and the sensation of breathlessness near the end of life, and the margin between therapeutic and excessive is not wide. What Resident 7 actually experienced during those three evenings is not recorded in the inspection report.
What is recorded is that the nurse entered the wrong number, the pharmacist reviewed the record and saw nothing wrong, and the system that was supposed to catch exactly this kind of error did not catch it. Pharmacist A told inspectors he confirmed he should have caught the incorrect concentration.
He missed it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy Park Health and Rehabilitation from 2025-02-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 14, 2026 · Our methodology
LEGACY PARK HEALTH AND REHABILITATION in KNOXVILLE, TN was cited for violations during a health inspection on February 27, 2025.
Instead, a licensed practical nurse transcribed the order using a different concentration, one that made each 0.25 ml dose equal to 5 mg.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.