Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that medications were properly labeled and stored for two residents. For one resident with cellulitis, an intravenous antibiotic (vancomycin) was found at the bedside with an incorrect label consisting of handwritten tape, rather than a pharmacy-issued label. The Director of Nursing confirmed that the IV should have had a proper pharmacy label and not a handwritten one. This improper labeling was directly observed during a survey. For another resident, several sachets of hydrocortisone 1% external gel were found in a bowl at the bedside, despite the absence of a physician's order for self-administration. The resident confirmed using the medication for a rash, and both a licensed nurse and the Director of Nursing stated that the ointment should have been stored in a locked treatment cart, not at the bedside. Facility policy also required all medications to be stored securely in locked compartments, accessible only to authorized personnel.