Federal inspectors found that Lions Rehab Center staff administered the incorrect morphine concentration to Resident #5 a total of 22 times between August 15 and August 24, despite having the correct medication available.
The medication error began on August 14 when a physician ordered 5 ml of morphine every three hours for the patient's pain. The original order specified a 10mg/5ml concentration, meaning each dose would deliver 10 milligrams of the painkiller.
Later that same day, the doctor changed the prescription. The new order called for 0.25ml of a much stronger 100mg/ml morphine solution every three hours as needed. This concentrated version would deliver 25 milligrams per dose — two and a half times more pain relief.
Both morphine solutions arrived at the facility on August 15. But nursing staff continued using the weaker 10mg/5ml version that had been discontinued the previous evening. They pulled 0.25ml from the wrong bottle 22 times over the next 10 days.
The error meant Resident #5 received just 0.5 milligrams of morphine per dose instead of the prescribed 25 milligrams — a 50-fold reduction in pain medication for someone in comfort care.
Registered Nurse #3 had read the initial morphine order back to the physician three times on August 14 at 10:54 AM to confirm accuracy. But by 10:31 PM that evening, Registered Nurse #4 documented that "the Morphine order was not delivered, and a new order was entered after discussion with the physician to use the morphine available in the facility."
The Director of Nursing told inspectors during an October 28 review that the discontinued 10mg/5ml morphine solution "should not have been delivered by the pharmacy since the order had been discontinued already." She confirmed that nursing staff "should have used the 100mg/ml solution initially."
Multiple nurses participated in the error over the 10-day period. Different staff members pulled the incorrect 0.25ml dose from the wrong morphine bottle during various shifts, suggesting systemic confusion about which medication to use.
The inspection began after complaints about Resident #5's ineffective pain management reached state regulators. A complaint filed as #2598971 alleged that despite being in comfort care, "the pain medication used was ineffective and the resident was complaining of pain and discomfort."
Narcotic count sheets reviewed by inspectors with the Director of Nursing revealed the pattern of incorrect dosing. The facility's own medication tracking showed staff consistently accessing the discontinued morphine rather than the prescribed concentrated version.
The Director of Nursing acknowledged the medication error during an October 29 discussion with inspectors. She "verbalized understanding and acknowledged the concern" that the facility had failed to keep Resident #5 free from significant medication errors.
Federal regulations require nursing homes to ensure residents are free from significant medication errors. The inspection classified this violation as causing "minimal harm or potential for actual harm," though the resident experienced ongoing pain complaints during the period of incorrect dosing.
The case illustrates how medication management failures can compound suffering for the most vulnerable patients. Resident #5 was receiving end-of-life comfort care, a setting where effective pain control is considered essential for dignity and quality of life.
The morphine dosing error persisted despite multiple safeguards that should have prevented it. The pharmacy delivered both medications despite one being discontinued. Nursing staff had access to both solutions but consistently chose the wrong one. And supervisory staff failed to catch the pattern during daily narcotic counts.
For 10 days, while Resident #5 complained of pain and discomfort, the facility's medication error meant each dose delivered 98% less pain relief than prescribed. The patient received half a milligram when doctors had ordered 25 milligrams — a difference that left someone in comfort care inadequately medicated during their final period of life.
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.