Failure to Ensure Proper Labeling and Storage of Resident's Multivitamin
Penalty
Summary
The facility failed to ensure that a resident's multivitamin liquid bottle was labeled with a manufacturer expiration date, as required by both manufacturer specifications and the facility's own policies and procedures. During an inspection of the medication room, surveyors observed a bottle of Marry Ruth's Liquid Morning Multivitamin Hair Growth stored in the medication refrigerator without a visible manufacturer expiration date. The bottle had a facility-applied handwritten label with the resident's information and an open date, but neither the LVN nor the DON could locate the manufacturer's expiration date, even after attempting to remove the facility label. The DON confirmed the importance of the expiration date for determining the safety and effectiveness of the medication and acknowledged that the multivitamin was a home medication brought in by the resident, but could not verify its source. Further review of the resident's records indicated that the resident had severe cognitive impairment and required significant assistance with activities of daily living. The multivitamin was being administered per physician order, and documentation showed it had been given multiple times. Interviews with staff confirmed that the medication was brought in sealed by the resident, but without an expiration date, staff could not determine how long the product had been in use. Facility policy required that medications brought in by residents or family members must have contents verified and packaging that meets state, federal, and pharmacy guidelines, and that medications be stored according to manufacturer recommendations to maintain integrity and safety. These requirements were not met in this instance.