Improper Labeling and Storage of Controlled Medications
Penalty
Summary
Facility staff failed to ensure that controlled medications were properly labeled and stored according to professional standards. A resident, an 84-year-old female with diagnoses including chronic obstructive pulmonary disease, pneumonia, weakness, and depression, was admitted on hospice services and brought Lorazepam 0.5mg tablets from home. Instead of keeping the medication in its original pharmacy packaging, staff repackaged the tablets into nine unlabeled clear plastic bags and a cup, with no resident name, medication name, directions, or description on the packaging. The repackaging was done to facilitate counting at shift change, but staff were unable to identify the tablets by appearance, and the original labeled bottle was empty. Both the RN and DON confirmed the presence of the repackaged, unlabeled controlled medication and were unsure who authorized the repackaging. Interviews with nursing staff revealed that the standard practice was to keep all narcotic medications in their original, clearly labeled pharmacy packaging. However, in this instance, the controlled medication was divided into multiple unlabeled bags, and the staff responsible for this action could not be identified. The facility's documentation showed the medication was received from a home supply and that counts were being performed at shift changes, but the lack of proper labeling and storage did not meet professional standards or regulatory requirements.