Barbara Lefforge entered Covenant Care of California, LLC (doing business as St. Edna's Subacute and Rehabilitation Center) to recover from tendon surgery. She was prescribed morphine for post-surgical pain whereupon the pharmacy notified St. Edna's staff that the morphine order was unusually high. Procedure requires that the resident's attending physician approve medication orders, but facility staff did not obtain the attending physician's approval to administer the morphine injection.

Ms. Lefforge began to exhibit signs of respiratory depression and was transferred to Garden Grove Emergency Room. She was later seen at UCLA Medical Center, where the neurology team concluded that she had suffered an anoxic brain injury as a result of the morphine overdose at St. Edna's. This resulted in deficits in coordination, executive function, reduced cognitive function, and impaired judgment. Ms. Lefforge spent more than six months after her discharge relearning how to walk, talk, eat, and groom herself. Since then, she has required 24-hour supervision to assist her with activities of daily living.