By Kelly Paice | inewsource

Click on the image for an interactive timeline of San Diego Hospice’s inspection results.

Earlier this week the KPBS and inewsource Investigations Desk learned about concerns regarding patient care at San Diego Hospice. It was the first indication the troubled hospice had more than money problems.

A further analysis of inspection records obtained through the federal Freedom of Information Act found San Diego Hospice was visited by government inspectors at least 15 times in 2011 and 2012. During this two-year period, there were multiple medication overdoses, including one patient who received 20 times the prescribed dose of morphine. That patient died an hour later.

Patient neglect also proved to be an issue, as another patient was found with pressure sores lying in a blood-stained bed. Twice investigators declared “immediate jeopardy” – a crisis situation in which “the health and safety of individual(s) are at risk,” according to the Centers for Medicare and Medicaid state operations manual.

Ten of the 15 visits found “no deficiencies.” Most of those visits were investigations into complaints and were not full surveys of the hospice.

Joanne Faryon is a freelance reporter and former inewsource and KPBS reporter.