Failure to Ensure Timely Availability and Proper Labeling of Routine Medications
Penalty
Summary
Staff failed to ensure that routine medications were available for two residents during medication administration. One resident did not receive a scheduled dose of Vitamin D3 1000 units because the medication was not present in the resident's supply, and the LPN confirmed it was not available in the medication storage room. The LPN stated she would order the medication from the pharmacy. In another instance, a resident with an order for Lantus insulin did not have a properly labeled multi-dose vial, as neither the box nor the vial was marked with an open date, and there was no back-up supply available. The LPN confirmed the absence of a back-up supply and reordered the insulin from the pharmacy. Facility policy requires that pharmacy services be available 24/7, that residents have a sufficient supply of prescribed medications, and that medications are labeled and stored according to standards. The policy also prohibits borrowing medications due to failure to order or reorder in time. The administrator stated that her expectation was for a back-up container of insulin to be available for each resident prescribed insulin and for medications to be available as ordered. These observations and interviews demonstrate that the facility did not follow its own policies regarding medication availability and labeling.