Medication Labeling Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that medication was labeled in accordance with accepted professional standards for a resident. The facility's policy on administering medications, last reviewed without changes on December 31, 2024, requires that medications be administered according to prescriber orders, with the individual administering the medication checking the label three times to verify the right resident, medication, dosage, time, and method of administration. However, during a medication administration pass, it was observed that an LPN prepared Clonazepam 0.5 mg for a resident, pouring two tablets for administration, despite the label instructing staff to administer one tablet by mouth twice daily and two tablets at bedtime. The discrepancy between the label instructions and the active physician's order, which required one tablet by mouth two times a day and two tablets in the afternoon, was confirmed by the LPN. The label indicated that the pharmacy filled 30 tablets on January 24, 2025, and there were 23 tablets available at the time of observation, suggesting that seven tablets had been administered before the LPN removed two additional tablets. The concerns regarding medication labeling were discussed with the Nursing Home Administrator and the Director of Nursing.
Plan Of Correction
1. Resident 14: The physician was immediately notified of the medication label discrepancy. No medication error occurred as the labeled only had discrepancy; nurses followed order in EHR system. The pharmacy was contacted, and a corrected label was issued to match the active physician's order. 2. A full house medication cart audit will be completed to ensure labels are cross-checked against physician orders. If discrepancies are identified, the pharmacy and physician will be notified immediately for resolution. If it is the same medication dosage but a change in time, a change in direction label will be placed on medication until new medication with updated labeling matching the order is received from the pharmacy. 3. The DON will provide re-education to licensed nursing staff on proper medication verification procedures, emphasizing the importance of ensuring that: - The medication label matches the active physician's order. - Any discrepancies are immediately reported to the pharmacy and physician before administration. 4. The Director of Nursing (DON) or designee will conduct random weekly audits of medication labels vs. physician orders for four weeks to ensure compliance, then monthly for 2 months. Medication label audit results will be reviewed in monthly QAPI to determine ongoing monitoring.