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F0755
E

Expired Morphine Administered to Resident

Van Nuys, California Survey Completed on 08-26-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with quadriplegia and hypotension, who was cognitively intact and fully dependent on staff for daily care, was administered morphine sulfate oral solution after the medication had expired. The medication order specified morphine sulfate 10 mg/5 mL to be given by mouth every eight hours as needed for severe leg/knee pain. Review of the Medication Administration Record (MAR) confirmed that the expired morphine sulfate was administered on multiple occasions after its expiration date. During interviews and record reviews, it was acknowledged by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) that the medication had expired prior to its administration. The DON confirmed that nurses are required to check expiration dates before administering medications and that expired medications should be removed and reordered, not given to residents. Facility policy also required checking expiration dates prior to administration, but this procedure was not followed in this instance.

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