§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
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Observations:
Based on review of clinical records and interview with staff and resident, it was determined the facility failed to ensure pain medication was administered in accordance with the physician's order for one of six residents reviewed for pain management (Resident R1).
Findings Include:
Review of Resident R1's clinical record revealed that R1 was admitted to the facility on April 1, 2022, with diagnoses of generalized abdominal pain, pain unspecified, hemorrhoids (rectal veins), interstitial pulmonary disease (lung fibrosis), bilateral carpal tunnel syndrome (wrist neuropathy), abrasion of the left breast, initial encounter (breast scrape), pruritus (itching), rheumatoid arthritis (inflammatory arthritis), and cervical spinal stenosis (neck stenosis).
Review of Resident R1's clinical record revealed a physician's order dated March 24, 2026, for Morphine Sulfate (Concentrate) Oral Solution 100 mg/5 ml, to give 0.75 ml by mouth every 4 hours as needed for pain rated 37/10 (0.75 ml = 15 mg).
On July 14, 2026, at 10:27 a.m., an interview was conducted with Resident R1, who reported that medications are not being administered timely. For example, the last time Resident R1 received his/her morphine was yesterday morning, July 13, 2026, because the facility was out of morphine. Resident R1 stated that he/she is supposed to receive morphine per physician's order every 10 days. One of the nurses had notified management that Resident R1's supply of morphine was running low, but the facility failed to order it ahead of time. Yesterday, Resident R1 received a prescription for morphine from the physician, and per his/her preference, she/his asked her spouse to go to the local pharmacy to fill it; however, the local pharmacy was out of morphine. The last dose Resident R1 received was yesterday morning.
On July 14, 2026, at 11:35 p.m., an interview with the DON, E2, confirmed that a review of Resident R1's Controlled Medication Utilization Record indicated that R1 received 0.05 ml on July 14, 2026, at 6:30 a.m., administered by licensed nurse E4 as the last documented dose. E2 further reported that the pharmacy delivered Resident R1's morphine 100 mg/5 ml early on July 14, 2026, between approximately 5:00 a.m. and 6:00 a.m. However, according to the DON, it is most likely that Employee E5 did not check the medication drop-off, and Resident R1 did not receive the full ordered dose of 0.75 ml but instead received 0.5 ml. A review of the Medication Administration Record (MAR) revealed that Resident R1 had a pain level of 9 documented on July 14, 2025, and received 0.5 ml of morphine at 6:20 a.m.
On July 14, 2026, at 11:35 p.m., an interview with the Unit Manager, Employee E3, revealed that licensed nurse E4 was not available for interview because she had completed the 11:00 p.m. to 7:00 a.m. night shift. Employee E3 confirmed that the pharmacy delivered Resident R1's medication, Morphine 100 mg/5 ml, early on July 14, 2026. Employee E3 brought the sealed, unopened bottle of Morphine 100 mg/5 ml and the Controlled Medication Utilization Record, which had not been signed out. Employee E3 reported that most likely Employee E4 did not check the nursing office to see that the medication was available and administered 0.05 ml of morphine instead of the ordered 0.75 ml.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
| | Plan of Correction - To be completed: 08/28/2026
R1 has had pain medication in accordance with physician order since survey.
Audits of residents receiving Morphine Sulfate Concentrate have shown no issues with administration per physician order.
DON/DSD will educate licensed nursing staff on medication administration. DON/designee will audit medication administration with Morphine Sulfate concentration to ensure medication is distributed per physician order weekly X 4 and then monthly X 4. Any issues will be addressed as soon as issue is noted.
Results of the audits will be submitted to the community quality assurance and performance improvement committee for review and recommendations.
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