Failure to Label and Date Inhaler in Medication Cart
Penalty
Summary
A deficiency was identified when an LPN was observed retrieving an inhaler from the medication cart for a resident, which was found to be unlabeled and undated. Upon inquiry, the LPN confirmed that there was no date opened on the inhaler. Review of the resident's physician order indicated the use of Ventolin HFA Inhalation Aerosol Solution, to be administered four times daily for shortness of breath. The resident's medical record showed a diagnosis of Alzheimer's disease, impaired cognition, and a need for assistance with activities of daily living, including medication administration. Further review of the facility's policy on medication management stated that medications are to be dated and discarded according to manufacturer guidelines. When questioned, the DON expressed uncertainty about the requirement to date inhalers and indicated a need to review the policy. The failure to label and date the inhaler as required by both facility policy and federal regulations led to the cited deficiency.
Plan Of Correction
Corrective action taken for resident 56. The unlabeled inhaler was removed from the cart and replaced with a new inhaler from pharmacy which was labeled and dated appropriately. All residents have the potential to be affected by the deficient practice. All med carts were audited by unit managers and no unlabeled/dated medications were found. The Medication Management Policy was reviewed by the IDT and deemed to be appropriate. All licensed nurses will be educated on the Medication Management Policy with an emphasis on labeling and dating medications according to manufacturer guidelines. Resident name labels have been made available at each nursing station. The DON/designee will conduct random audits of the medication carts to ensure that all medication are appropriately labeled and dated. These audits will be weekly x4 weeks and then monthly x2 until compliance has been maintained. The results will be brought to QAPI for further recommendations. The DON/NHA are responsible for continued compliance.