Failure to Ensure Accurate Medication Labeling and Timely Pharmacy Notification
Penalty
Summary
A deficiency occurred when a resident with diabetes, complicated by retinopathy, was found to have a discrepancy between the insulin dosage instructions on the medication bottle and the physician's current order as reflected in the electronic Medication Administration Record (eMAR). The insulin bottle label instructed administration of 28 units at bedtime, while the eMAR indicated a current order of 25 units to be given twice daily. The resident's insulin order had been changed multiple times in recent weeks, but the medication label had not been updated to reflect the most recent physician's order. During medication administration, two licensed nurses confirmed the discrepancy and agreed that the pharmacy should be notified to correct the label. However, there was no documentation to show that the pharmacy had been informed or that the medication had been sent for relabeling. Facility policy requires that any discrepancy between the eMAR and medication label be resolved by checking the physician's order and sending the medication to the pharmacy for relabeling if necessary. This process was not followed, resulting in the continued presence of a mislabeled medication in the facility.