Medication Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to accurately label medications for a census of 61 residents, leading to potential medication errors. Specifically, Resident 54's insulin order was not correctly reflected on the medication label. During a medication administration observation, a licensed nurse administered 14 units of Humulin N to the resident, while the medication label indicated a dosage of 10 units. The Medication Administration Record confirmed the physician's order for 14 units every morning and night, but the label had not been updated to reflect this change. The Director of Nursing confirmed that the facility's policy required a 'change in direction' sticker on the medication and a new label from the pharmacy when orders change. Additionally, during an inspection of a medication storage cart, several medications were found without resident labels or open dates, and one label was difficult to read. These included Biktarvy, Breyna Inhalation Aerosol, and Symbicort Inhalation Aerosol, among others. The Director of Nursing confirmed that the labels were illegible or missing, and the medications should have been sent to the pharmacy for proper labeling. The facility's policy indicated that any inadequately or improperly labeled medications should be returned to the issuing pharmacy for correction.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Upon identification of the alleged deficient practice, the following were conducted: a. Resident 54's insulin label was immediately corrected to reflect the correct order. New NPH insulin was also ordered from the Pharmacy with the updated label. Resident 54 was assessed for signs and symptoms of hyper/hypoglycemia, none were observed. b. New Inhaler medications were ordered from the facility pharmacy. c. The three (3) Inhalation Aerosols and Biktarvy were shown to the Pharmacy Consultant, reviewed and verified the medications during his visit on 3/24/2025. All Medications were properly labeled to indicate proper identification, right dosage and expiration. d. The Lidocaine and Inhalation powder that had no open dates were immediately discarded and new medications were ordered from the pharmacy. Pharmacy Consultant informed pharmacy to deliver a new sticker indicating the right identification and dosages of the medication. 1:1 in service education provided by the Director of Nursing Services (DNS) on 03/11/2025 to LN1. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this alleged deficient practice as failure to correctly label medication could result in providing wrong medications, incorrect dosages, and expired medications to residents. An immediate sweep of medication carts station 1 and station 2 was conducted by the Director of Staff Development (DSD) to ensure there were no additional medications with lacking resident labels and open dates, and the label that was unclear and difficult to read. No other residents were found to be affected at this time. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: It is the policy of the facility that medication must be properly labeled consistent to the order, labels must be legible at all times and any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. 1:1 in service education provided by the DNS on 03/11/2025 to Licensed Nurse 1 (LN 1) and to other LNs regarding the policies and procedures on "Labeling of Medication Containers" and "Storage of Medications" with emphasis on the following: a. Ensuring that medications are properly labeled including medications brought by family into the facility. b. Returning to the issuing pharmacy any medications that are improperly labeled. c. Notifying the pharmacy of any changes in the physician's orders. Upon receipt of any delivery of medication from the pharmacy, LNs must ensure medications are properly labeled. The issuing Pharmacy must be notified for any issues. During medication pass, LNs must ensure that medications are properly labeled consistent to the order. Any medication brought by the family to the facility must be verified and ensure that proper labels are available. Any issues will be communicated to the DNS and the facility pharmacy. How the facility plans to monitor its performance to make sure that solutions are sustained: The DNS/Designee will audit Medication carts at Station 1&2 bi-weekly x 3 months to ensure compliance. Findings identified will be presented to the monthly QAPI meeting for 3 months for follow-up and recommendations. The administrator will bring 2567 and POC to the QAPI meeting to discuss and ensure understanding for the next 3 months or until substantial compliance is achieved. Completion Date: 03/24/2025 During a review of the facility's P&P titled, F 761