Unlabeled Loose Pills Found in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional principles. During an observation of the 200 hall nurse cart, five pills were found loose in the bottom of the cart, not in labeled containers. This was confirmed through interviews with the Assistant Director of Nursing (ADON), the Acting Administrator, and an LVN, all of whom acknowledged the risk of confusion and the possibility that medications could be given to the wrong patient or that patients might not receive their prescribed medications. The staff also indicated that while narcotics are routinely counted, there is not a consistent process for checking for and addressing loose pills in the medication carts. A review of the facility's Medication Labeling Policy from the Pharmacy Policy & Procedure Manual indicated that all medications must be properly labeled as required by state regulations, and non-prescription drugs must be in their original manufacturer's container. The presence of unlabeled, loose pills in the medication cart demonstrates a failure to follow these established policies and procedures for medication labeling and storage.