Medication Labeling Discrepancies in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled safely and accurately, as observed during medication administration for two residents. In one instance, a discrepancy was noted between the Electronic Medication Administration Record (eMAR) and the actual medication label for Eliquis, where the eMAR indicated a 5 mg dose, but the label instructed a 10 mg dose. The registered nurse did not administer the medication and opted to call the physician for clarification. In another case, discrepancies were found for a resident's medications, where the eMAR and medication labels did not match for Sodium Chloride and Levetiracetam, leading the licensed practical nurse to refrain from administering the medications and seek clarification from the physician. The report highlights that the facility's process for handling medication order changes was not consistently followed. Nurses explained that when orders were changed, they would update the order, reorder the medication, and remove the old blister pack from the cart. However, discrepancies in medication labeling persisted, as evidenced by the observations. The consultant pharmacist, who conducted monthly audits, did not verify the eMAR against the medication labels, which contributed to the oversight. The facility's policy required that medications with incorrect labels be returned to the pharmacy, but this was not adhered to, resulting in potential medication errors.