Medication Labeling Error During Administration
Penalty
Summary
The facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles. This deficiency was identified during an observation of medication administration for a resident, where a licensed nurse administered a nasal spray labeled with another resident's name. The facility's policy on medication administration requires that medications be administered safely and as prescribed, with the individual administering the medication verifying the resident's identity and checking the label three times to ensure the right resident, medication, dosage, time, and method of administration. In this case, the nurse picked up a box labeled with the current resident's name and room number but administered a nasal spray bottle that had a typewritten label with a different resident's name. The nurse confirmed that the bottle used was incorrectly labeled with another resident's name. This incident involved a resident who was admitted with a diagnosis of Acute Sinusitis and had a physician's order for Fluticasone Propionate Nasal Suspension. The error was discovered during a medication administration observation, highlighting a failure in the facility's medication labeling and administration process.
Plan Of Correction
Resident R42's fluticasone propionate was placed in the correct box. House wide audit completed to ensure that medication were properly and accurately labeled in accordance with currently accepted professional principles. Licensed staff will be in-serviced to ensure that medications are properly and accurately labeled in accordance with currently accepted professional principles. The Director of Nursing/Designee will conduct a random audit of 5 residents' medications to ensure that they are properly and accurately labeled in accordance with currently accepted professional principles. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.