Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications in accordance with accepted professional principles, as observed during a recertification survey. Specifically, multiple eye drops in the Unit 1 medication cart were not appropriately labeled or dated. The facility's policy on Equipment and Supplies for Administering Medications did not address pharmaceutical labeling or medication safety. During an observation, it was found that several medications, including latanoprost eye drops and artificial tears, lacked pharmacy labels and had the tops of their boxes ripped off. The names of the residents were written inside the boxes with a black magic marker, but there were no visible instructions for administration. Interviews with staff revealed that all medications should have pharmaceutical labels, and the absence of such labels posed a risk of administering the wrong medication. Licensed Practical Nurse #2 acknowledged the issue and stated that the pharmacy should have been notified. The Unit Manager and the Director of Nursing confirmed that prescription medications like latanoprost should have proper labels, and artificial tears, although a stock item, should have a resident-specific label. The Director of Nursing emphasized that eye drops must be dated when opened and should remain in the original box with the pharmacy label to prevent the risk of residents receiving the wrong medication.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The medication carts were audited on 2/14/2025. All eye drops that were found outside of the box or unlabeled were discarded. New eye drops were obtained for each of the residents affected (Resident #8, Resident #12, and Resident #20). All residents with an order for [REDACTED]. All over-the-counter eye drops had a resident label with the date of open applied. The Director of Nursing will ensure an audit of each medication cart is done bimonthly to ensure that all eye drops are correctly labeled. LPN and RN employees were initiated education on 3/3/2025 on proper labeling of eye drops. The Audit tool will be reviewed quarterly with the Quality Assurance and Performance Improvement Meeting for 1 year to ensure compliance. Date of Correction: 3/3/2025 Person Responsible for Correction: Director of Nursing