Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional principles. During an observation of medication administration, it was found that a nurse administered a nasal spray to a resident using a bottle labeled with another resident's name. Specifically, the bottle of Fluticasone nasal spray used for Resident R42 was labeled with Resident R78's name, despite being administered to Resident R42. This discrepancy was confirmed during an interview with the nurse at the time of the observation. Resident R42 was admitted to the facility with a diagnosis of acute sinusitis and had a physician's order for Fluticasone Propionate Nasal Suspension for allergy relief. Resident R78, who had been discharged from the facility, had a similar order for the same medication, which was discontinued upon discharge. The facility's policy requires that medications be administered safely and as prescribed, with verification of the resident's identity and medication label checks. However, these procedures were not followed, leading to the administration of medication with incorrect labeling.
Plan Of Correction
Resident R42's fluticasone propionate was placed in the correct box. A house-wide audit was completed to ensure that medications were properly and accurately labeled in accordance with currently accepted professional standards. 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.