Medication Labeling and Pharmaceutical Service Deficiencies
Penalty
Summary
The facility failed to correctly label medications and ensure the accurate provision of pharmaceutical services for multiple residents. During an observation of the medication room, two insulin pens belonging to two residents were found in the medication refrigerator with incorrect labeling; the last names were misspelled and labeled using the second letter of the residents' last names. This was confirmed by an LPN and the Director of Nursing. Additionally, the facility's policies require thorough medication regimen reviews and emergency drug services, but these were not properly implemented. Further review of clinical records revealed that two other residents did not receive their prescribed medications as ordered. One resident, with diagnoses including atrial fibrillation, breast neoplasm, and osteoarthritis, had orders for Lidocaine Viscous and Kool 'N Fit Spray that were either awaiting delivery or not being filled by the pharmacy. Another resident, diagnosed with acute respiratory failure with hypoxia and kidney transplant rejection, had orders for Repatha and Biotin Forte that were not administered as prescribed. These failures were confirmed by nursing staff and the Director of Nursing.