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F0761
E

Failure to Label Ophthalmic Solutions

Philadelphia, Pennsylvania Survey Completed on 01-15-2025

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

The facility failed to properly label medications upon opening, specifically ophthalmic solutions, on two of the three medication carts observed on the third floor. During a medication pass on January 12, 2024, it was observed that seven boxes of multi-use eye drops on medication cart one and two boxes on medication cart two did not have the date of opening labeled on them. This was confirmed through interviews with the licensed nurses, Employee E5 and Employee E6, who were responsible for the medication carts at the time of the observation. The facility's policy titled "Medication Labeling and Storage" requires that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a longer date for the open vial. The failure to label the date of opening on the multi-use eye drops is a deviation from this policy. The report does not mention any specific residents affected by this deficiency, nor does it provide details on any immediate consequences resulting from the oversight.

Plan Of Correction

1) Eye drops in both medication carts have been replaced and labeled correctly with date they were opened. 2) All Medication carts have been audited to ensure all eye drops have been dated upon opening. 3) Licensed nursing staff will be educated by Director of Nursing / designee on medication storage and labeling. 4) Director of Nursing / designee will conduct random audits of medication carts weekly x 3, then monthly x 2 or until compliance is met to ensure proper medication storage and labeling on medication carts. Variances will be addressed and reported to the QAA Committee.

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