Medication Labeling Deficiency
Penalty
Summary
The facility failed to ensure that all drugs used were labeled in accordance with clinical professional standards. During an inspection of a medication cart on two floors, it was observed that two translucent brown medication bottles had labels with spaces to write the medication expiration date and the date opened, but no information was filled in. Additionally, an injector pen was found with a label to document the 'date opened' and instructions to discard after 28 days, but these dates were not documented. Staff A, a Registered Nurse, admitted to not knowing the expiration dates for the medications and acknowledged that the labels should have been dated. Further inspection on the second floor revealed another injector pen without the open date and discard date listed. Staff B, an LPN, confirmed that the medication should be discarded 28 days after first use and immediately removed the injector pen from the cart. The Director of Nursing stated that the facility expects staff to write the medication expiration dates on the labels when medications are first used. The facility's policy on medication administration requires identifying expiration dates and notifying the nurse manager if medications are expired.
Plan Of Correction
Identified and injector pens were discarded on 04/23/2025. On 04/23/2025, new medications were provided by the pharmacy and dated appropriately. Quality review was conducted by the Director of Nursing/designee of current medication carts to ensure proper labeling/storage of drugs and biologicals, with emphasis on medications being dated at time of opening and discarding medication when expired. Any concerns noted were addressed as identified. Current Licensed Nurses were re-educated by the Director of Nursing/designee on the components of this regulation, with emphasis on ensuring proper labeling/storage of drugs and biologicals, with emphasis on medications being dated at time of opening and discarded at time of expiration. The Director of Nursing/designee will conduct quality monitoring of medication carts to ensure proper labeling/storage of drugs and biologicals, with emphasis on medications not being dated when opened and expired drugs twice weekly for 4 weeks, weekly for 2 weeks; then weekly and PRN as indicated. The findings of these quality monitoring activities will be reported to the Quality Assurance/Performance Improvement Committee monthly. The quality monitoring schedule will be modified based on findings, with quarterly monitoring by the Regional Director of Clinical Services/designee.