The licensed practical nurse, identified as LPN #5 in inspection records, pulled 0.25ml doses from a morphine solution between August 15 and August 24. But medication administration records showed no documentation that she actually gave the drug to Resident #5 on five occasions: August 15 at 2 PM, August 17 at 2:30 PM, and three times on August 22 at 8:30 AM, 2:20 PM and 8 PM.
The resident had been placed on comfort care with a physician's verbal order on August 14 to administer 5ml of morphine every three hours for pain and discontinue all other medications. The morphine solution arrived the next day with a concentration of 10mg per 5ml.
Inspectors discovered the discrepancy on October 28 while reviewing the facility's narcotic count sheet with the Director of Nursing. They compared entries showing when morphine was withdrawn from stock against the electronic medication administration record that documents when drugs are actually given to patients.
The investigation began after someone filed complaint #2598971 alleging that Resident #5 was not receiving ordered pain medication. Progress notes confirmed the resident was on comfort care and should have been receiving morphine every three hours.
Different nurses had pulled the morphine solution 22 times total during the nine-day period, but only LPN #5's withdrawals showed no corresponding administration records. All other nursing staff properly documented giving the medication after withdrawing it from stock.
When confronted with the findings on October 28, the Director of Nursing said she would review the resident's medical records. The next day, she confirmed that LPN #5 had no documentation showing she administered the medication on the five dates in question.
The Director of Nursing told inspectors she had contacted the staffing agency for clarification but received no response. She placed LPN #5 on a list of agency staff not allowed to return to the facility.
The case illustrates gaps in oversight of temporary nursing staff at a time when many facilities rely heavily on agency workers to fill staffing shortages. Agency nurses often work at multiple facilities and may be less familiar with specific protocols and documentation requirements.
For patients receiving comfort care, consistent pain management becomes critical as families seek to ensure their loved ones' final days are free from suffering. Missing doses of morphine can leave dying patients in unnecessary pain during their most vulnerable moments.
Lions Rehab Center's failure to ensure accurate medication dispensing and administration affected at least one resident receiving end-of-life care. The facility acknowledged the violation when inspectors presented their findings on October 29.
Federal regulations require nursing homes to provide pharmaceutical services that meet each resident's needs and employ or obtain services from licensed pharmacists. This includes maintaining accurate records of controlled substances like morphine and ensuring medications are actually administered when withdrawn from stock.
The inspection found minimal harm or potential for actual harm affecting few residents. But for Resident #5's family, the missing morphine doses during comfort care represented a fundamental breach of trust during one of life's most difficult transitions.
The Director of Nursing verbalized understanding of the concern and acknowledged the facility's failure to ensure proper medication handling. However, the inspection report provides no details about what corrective measures Lions Rehab Center planned to implement beyond banning the agency nurse from returning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lions Rehab Center from 2025-10-29 including all violations, facility responses, and corrective action plans.