Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, specifically Morphine Sulfate Solution, for a resident diagnosed with dementia and polyneuropathy. The medication was not labeled with the appropriate expiration or open dates, leading to its use well beyond the recommended 28-day period after opening. The Morphine Sulfate Solution was administered to the resident over a span of 20 months for one bottle and 18 months for another, far exceeding the guidelines for safe use. Staff interviews and observations revealed that the medication was administered multiple times without checking for expiration or open dates. An LPN noted the medication's color was faded, indicating potential degradation, yet continued to administer it without verifying its validity. Additionally, a new bottle retrieved from the emergency supply was found to be unlabeled, lacking essential information such as the medication name, concentration, dosing instructions, and prescribing provider. The Director of Nursing confirmed that the facility did not monitor the open or expiration dates of the medications, and staff failed to label the emergency supply medication properly. This oversight resulted in the administration of an unlabeled narcotic medication to the resident for nearly a month. The facility did not adhere to medication labeling protocols, leading to the use of expired and improperly labeled medications.
Plan Of Correction
The facility corrected the medication labeling error for resident 28 prior to the end of the survey. The pharmacy will be providing the facility with preprinted medication labels on cubex items to say, "see MAR for directions." The licensed nursing staff will write the date and the resident name on the label. The pharmacy policy will be updated regarding these changes. The licensed nursing staff will be educated regarding the updated pharmacy policy and procedure. The licensed nursing staff will be educated regarding the accuracy and completeness of the controlled drug count sheet. Monthly audits x 3 months will be completed by the DON/designee of the controlled drug count sheet including but not limited to comparing it to the MD order and correct medication and label. Results of the audits will be reviewed at monthly QAPI x 3 months.