Lake Country Health Services: Morphine Underdosing - WI

The inspection, completed March 12, 2025, was triggered by a complaint. What investigators found at the center on North Summit Village Way was a controlled substance record that didn't match the doctor's orders, a nurse who was no longer employed, and a resident who had gone hours without adequate pain relief.

The resident, identified in inspection records only as R1, had been prescribed Morphine Sulfate Concentrate Oral Solution at 0.5 milliliters by mouth every two hours on a scheduled basis for pain. The order was clear. The dose was specific. But on one evening shift, Licensed Practical Nurse M administered 0.25 milliliters, half the prescribed amount, at 4:00 p.m. Then again at 6:00 p.m. Then again at 8:00 p.m. Then again at 10:00 p.m.

Four consecutive doses. Each one half of what the physician had ordered. Eight hours.

Inspectors reviewed the resident's pain level scores across multiple shifts in the days surrounding the incident. The records showed a pattern of documented pain. The morphine had been ordered not only for pain but for shortness of breath, a combination that signals a resident in serious physical distress, likely in the final stages of illness. An earlier order had authorized 0.25 milliliters every two hours as needed for moderate to severe pain and shortness of breath. The later, scheduled order escalated that to 0.5 milliliters every two hours on a fixed schedule, meaning the clinical picture had worsened enough that a physician decided the resident needed medication around the clock, not just on request.

The Director of Nursing, identified as DON-B, told the inspector that the facility discovered the error on the evening it occurred. Staff reviewed R1's morphine orders, pulled the controlled substance records, and physically assessed the opened morphine bottle. The math confirmed it: LPN-M had given 0.25 milliliters four times when 0.5 milliliters had been ordered each time.

The facility classified it as a medication variance.

When the inspector asked to speak with LPN-M on the day of the interview, DON-B said the nurse was no longer employed at the facility.

The inspection report does not say when LPN-M left, why, or whether the departure was connected to the incident. It does not say whether the resident was assessed for unrelieved pain during those eight hours, or whether any corrective dose was given after the error was discovered. It does not say whether the resident's family was notified.

What it does say is that when the surveyor sat down with the Nursing Home Administrator, DON-B, a Regional Nurse Consultant, and a Vice President of Success at 2:30 in the afternoon, the facility offered nothing further. "The facility did not provide any additional information to Surveyor at this time."

The violation was cited under F0760, which covers the right of residents to be free from medication errors. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that only a few residents were affected.

That classification sits uneasily against what the records show. A resident with documented pain, prescribed a scheduled narcotic to manage both pain and difficulty breathing, received a systematically reduced dose across an entire evening shift. Whether that resident suffered more than they should have during those eight hours, the inspection report does not say. The nurse who could answer that question is gone.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Lake Country Health Services from 2025-03-12 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Lake Country Health Services
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