F0755

D

Failure to Provide Ordered Morphine Due to Pharmacy Unavailability

Myerstown, Pennsylvania Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to ensure a prescribed medication was available from the pharmacy for administration as ordered by the physician for one of three sampled residents. The resident was admitted on a specified date with diagnoses including kidney failure, COPD, respiratory failure, metabolic encephalopathy, and a urinary tract infection. On the day of admission, at 12:06 p.m., the physician ordered 0.25 ml of a morphine solution (20 mg/ml) to be administered every four hours. According to the Medication Administration Record, the resident did not receive any doses of the ordered morphine on two consecutive days because the medication was not available from the pharmacy.

In an interview conducted on a later date at 10:45 a.m., the Director of Nursing confirmed that the resident did not receive the morphine as ordered until another specified date at 12:00 a.m. This failure to provide the ordered medication was cited under 28 Pa. Code 211.9(d) related to pharmacy services and 28 Pa. Code 211.12(d)(1)(3)(5) related to nursing services.