Sacred Heart Hospice

“Based on record review and interview, the agency failed to discuss their policy for managing the safe use of controlled substance prescription drugs with the Patient and caregiver in a language and manner they understood in 1 out of 3 Patient records reviews (Patient 2), in that:The Agency failed to provide education on the safe use, storage, and disposal of controlled substance prescription drugs after ordering Patient 2 a “Comfort Pack”, which resulted in Patient 2 taking an overdose of Morphine (a strong opioid pain medication) requiring hospitalization. This failure resulted in an overdose of Morphine which required hospitalization due to unsafe usage and storage of Morphine. Findings included: Record review of Patient 2’s medical record revealed a document titled, “Plan of Care Order,” dated for the benefit period of 6/18/26 - 9/15/26, which revealed Patient 2 had a terminal diagnosis of “senile degeneration of brain,” (a term used to describe the progressive, age-related decline in cognitive function). Further review of the document revealed a Start of Care date of 6/18/26, with Skilled Nursing ordered 1-2/week, Medical Social Worker and Chaplain services ordered 1/month, and Hospice Aide services ordered 3/week. Further review of this document revealed a list of the Patients ordered medications, which included “Morphine Sulfate (concentrate) oral solution 20 mg/ml, with a dose of 0.25 mL, a frequency of every 2 hours as needed, and the following instructions: take 0.25 mL PO or SL every 3 hours as needed for moderate pain or dyspnea (trouble breathing)” Record review of the document titled, “Master Calendar,” undated, showed a calendar of Patient 2’s visits in the benefit period. On 6/18/26, it showed the RN initial Assessment was completed. On Friday, 6/19/26, it showed there was a missed visit (MV) for skilled nursing. On Saturday, 6/20/26, it showed the Patient was discharged for hospice services. Record review of the document titled, “Patient Communication,” digitally signed by RN B and dated 6/19/26, revealed a note from RN B which read: “Late entry 6/19/26: Call placed to [FM 2] to schedule pre-planned tuck in visit. [FM 2] stated patient wasn’t feeling well and preferred to move visit to the following Monday. Mentioned that a package from [local pharmacy] had arrived at which time I explained this was the comfort pack discussed during admission and reviewed the contents of the package, which medications were contained including Morphine (potent opiate analgesic used to treat moderate to severe acute and chronic pain), Lorazepam (primarily used for the short-term relief of severe anxiety, anxiety-related insomnia, and to stop acute seizures),Senna (used to treat constipation), ondansetron (used to treat nausea), Bisacodyl (used to treat constipation), and indications for each. [FM 2] stated pt had no symptoms needing any of those medications so we agreed to review them at length at our visit on Monday, or if she had any further questions about them until that time to call [Hospice 1] 24/7.Record review of Patient 3’s chart revealed a documented titled, “Comfort Pack Medications Teaching,” dated 11/7/25, detailing the medications in the “Comfort Pack” and signed by an RN and the Patient’s caregiver. No such document was found for Patient 2 in Patient 2’s medical record. In an interview with FM 2 at 2:13 PM on 7/6/26, FM 2 stated that the afternoon following RN B’s visit, FM 2 received a telephone call from the pharmacy. She stated the pharmacy delivered medications at approximately 3:00 p.m. the next day (6/19/26), including Lorazepam and Morphine. FM 2 stated she asked the pharmacy employee what the Morphine was for and was told it was “to make him comfortable.” She stated she never received counseling regarding the morphine from RN B. She stated she did talk to RN B on the phone to request the visit on 6/19/26 be moved to the following Monday. FM 1 stated they did not discuss the Comfort Pack medications in detail, she did not feel like she was sufficiently educated on the risks of having morphine in the home, and they did not discuss safe storage of the Comfort Pack. She stated that around 7:00 p.m., Patient 2 told her that he was going to take a small amount of the morphine (self-administered), which FM 2 stated she was aware of and in agreement with. FM 2 stated Patient 2 experienced some pain on occasion but not severe pain and that Patient 2 wanted to try a small amount of Morphine to determine whether it would relieve his discomfort. FM 2 stated that at approximately 9:00 p.m., Patient 2 fell asleep on the sofa, which she said was not unusual for him. She stated she went to bed early and allowed Patient 2 to remain on the sofa. FM 2 stated that the following morning Patient 2 remained asleep on the sofa. She stated she was not initially alarmed because he frequently slept late and planned to wake him around 10:00 a.m. She stated that after taking a shower, she noticed Patient 2 was breathing very shallowly. She stated she called another family member, who came to the house immediately and recommended calling 911. FM 2 stated they attempted to wake Patient 2 by shaking him, but he was unresponsive. She stated EMS arrived promptly and administered Narcan (brand name for naloxone, a life-saving, over-the-counter medication used to rapidly reverse an opioid overdose). FM 2 stated Patient 2 remained in the hospital. She stated the episode of shallow breathing resulted in pneumonia (infection of the lungs) and that Patient 2 remained too weak to walk with a decline in cognition. A telephone interview was conducted at 9:00 AM on 7/7/26 with RN B. RN B stated she completed Patient 2’s admission on June 18, 2026. She reported FM 2 was present during the visit and stated she sought hospice services due to increasing caregiver burden related to Patient 2’s progressive dementia (progressive decline in cognitive abilities and memory). She stated a “tuck-in” visit was initially planned for the following day but was postponed at the family’s request and rescheduled for the following Monday. RN B stated the purpose of a tuck-in visit is a follow up visit the day after admission. During this time, the nurse was expected to review the comfort medications, complete remaining nursing admission paperwork, and perform additional safety education. The Surveyor asked if the “tuck-in” visit was typically where the nurse would have the Patient/caregiver sign the “Comfort Pack Medications Teaching” form. RN B stated that yes, the “tuck-in” visit was typically where the “Comfort Pack Medications Teaching” form, as the Comfort Pack was typically delivered between the first visit and the “tuck-in” visit, and was when the Comfort Pack medications were gone over in detail. RN B stated the hospice election and consent forms had already been completed prior to her admission visit by Liaison B. Regarding the hospice “Comfort Pack”, RN B stated it was standard practice for most hospice patients to receive the medications shortly after admission. She stated the kit was ordered later on the day of admission and typically included morphine, lorazepam, senna, ondansetron (medication used to treat nausea/upset stomach), acetaminophen (used to treat minor pain and fever) suppositories (medication in the rectum for absorption), and bisacodyl (fast acting laxative) suppositories. She stated she discussed the “Comfort Pack” with FM 2 during the admission visit, and the FM 2 agreed to receive it. RN B stated Patient 2 was not experiencing pain at the time of admission, and the only medication discussed for possible use was Lorazepam at bedtime for agitation. She confirmed she did the admission visit on 6/18/26, and that the “Comfort Pack” medications, including the Morphine, were delivered on 6/19/26. She stated that she spoke on the phone with FM 2 on 6/19, when FM 2 requested they move the tuck-in visit to the following Monday. RN B stated that during this call, FM 2 stated the medications had been delivered, and RN B stated she “did a quick review” with her over the phone and reminded FM 2 about their conversation about the “Comfort Pack” the day before. The Surveyor asked what this review consisted of, and RN stated she reminded FM 2 how they had discussed Patient 2 would likely not need most of the medications in the Comfort Pack right now, but could benefit from the Lorazepam at bedtime. RN B stated she directed FM 2 to follow the instructions on the bottle if needed. RN B stated she did not go over safe handing, storage, and disposal of the Comfort Pack medications, and did not discuss potential dangers and side effects. RN B stated that was the last time she spoke with Patient 2’s family until the following Monday, when she came in to work and saw a note that Patient 2 had been admitted to the hospital. RN B stated she called FM 2 that day on 6/22/26 to discuss what had happened. RN B stated FM 2 informed her that Patient 2 had taken one dose of morphine from the “Comfort Pack” “to try it out” before the medication was left on the counter overnight. She stated Patient 2 did not come to bed, and the following morning his wife found him unresponsive with shallow breathing. She stated emergency medical services were contacted and Narcan (opioid reversal agent) was given by EMS. RN B stated FM 3 never found the morphine bottle, and the amount taken by Patient 2 was unknown. An interview was conducted with the Administrator at 4:10 PM on 7/7/26. The Administrator stated that “Comfort Packs” were not ordered for every patient upon admission. Instead, the decision was made by the RN Case Manager (RNCM) based on the patient’s needs. The RNCM could order the “Comfort Pack” directly, or the Director of Nursing (DON) could place the order at the RNCM’s request. The Administrator stated that, according to agency policy, the admitting nurse was responsible for providing education to the patient and/or caregiver regarding the safe use, storage, and disposal of medications contained in the “Comfort Pack”. The education was to be provided verbally in a manner the patient or caregiver could understand. The Administrator stated that while the marketer often reviewed the agency’s medication management policy with the patient or caregiver and obtained their signature acknowledging receipt of the information, the admitting RN was expected to provide detailed education after the “Comfort Pack” had been ordered. The Administrator stated that educating patients and caregivers regarding the safe use and storage of controlled substances was important to prevent medication errors, accidental misuse, and other adverse patient safety events. An interview was conducted with RN B at 5:45 PM on 7/7/26. RN B stated the “Comfort Pack” was ordered by the Director of Nursing (DON) (former SN) after the admission visit and arrived the following day. RN B stated there were no controlled substances in the home during the admission visit, so she did not specifically provide education on their safe use or storage at that time. She stated her plan was to review all medications and provide the appropriate education during the “tuck-in” visit after the “Comfort Pack” had been delivered. She stated she was not certain of the agency’s specific policy regarding education on controlled substances but knew the agency had lock boxes available and could locate the policy if needed. RN B stated education on the safe handling of controlled substances was important to Patient care because hospice nurses were responsible for educating patients and caregivers about prescribed medications before they are used.An interview was conducted at 8:55 AM on 7/8/26 with Liaison B. Liaison B stated that during the hospice admission process, she obtained the required consent forms but did not provide the patient with the policies and educational materials. She explained that these were supposed to be provided later by the admitting RN. Liaison B stated she reviewed the consent forms that referenced the agency’s policies, including topics such as patient rights, HIPAA, home safety, and other agency policies. She informed patients that these materials would be reviewed in detail by the admitting nurse and encouraged them to write down any questions for the nurse to address. Liaison B stated she did not provide detailed education regarding the policies because the information was clinical in nature and was the responsibility of the admitting nurse. She specifically confirmed that she did not provide Patient 2 with education regarding narcotic safety or the safe storage and use of controlled medications, and stated that this education was the responsibility of the nursing staff.Record review of the agency’s policy titled, “Disposal of Controlled Substances,” last reviewed 7/1/25, revealed a statement that read: “Upon admission the hospice will: provide a copy of the written policies and procedures on the management and disposal of controlled drugs to the patient or representative; discuss the policies and procedures for managing the safe use and disposal of controlled drugs, in a manner that is understood to ensure all parties are educated on the safe use and disposal of controlled drugs; document in the patients record that the policies and procedures were provided and discussed.””