Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to securely store medications and ensure proper medication labeling, leading to deficiencies in nursing services and pharmacy services. During a medication administration pass, an LPN crushed a Rosuvastatin tablet for a resident, despite the medication resource indicating that the tablet should be swallowed whole. The LPN confirmed that there were no instructions on the medication labeling from the pharmacy to indicate that the medication should not be crushed, and she was unaware of this precaution. Additionally, a registered nurse confirmed that the facility's medication resource also stipulated that Rosuvastatin should not be crushed. This indicates a failure in ensuring that all medication labeling included appropriate precautionary instructions. Furthermore, an observation in the main dining area of Unit One revealed a yellow-colored, round pill on the floor behind a television stand. An LPN was unable to identify the pill and proceeded to dispose of it. This incident highlights a failure in securely storing medications, as the pill was found in a common area accessible to residents and staff. The findings were reviewed in a meeting with the Nursing Home Administrator, indicating a lapse in the facility's medication storage protocols.
Plan Of Correction
1. Resident 46 was not harmed. Facility Supervisor checked with Pharmacist about Resident 46's medication tablet and the Pharmacist indicated that the medication "could be crushed" in tablet form. Resident was not harmed due to the tablet of medication being crushed. 2. The Director of Nursing reviewed any residents who required medications to be crushed to ensure contraindications was labeled on the medication label. 3. The Director of Nursing educated the Nurses on the importance of reviewing medications for proper labeling and securing medications to ensure no pills are left on the floor. 4. The Director of Nursing and or designee will complete weekly random audits for one month and monthly audits for three months to ensure proper labeling and medications are secure. These audits will be brought to the monthly quality assurance monthly meeting.