Failure to Properly Label, Date, and Store Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure medications were properly labeled and dated when opened for two residents. During inspection of medication carts on two separate units, it was found that one resident's morphine sulfate, used for palliative pain management, was opened but not dated, and the controlled drug receipt indicated the medication had been delivered previously. Another resident's diazepam, administered for seizures, had a label that was illegible and nearly detached, and the medication was also opened without being dated. Additionally, the diazepam had expired approximately four months prior, and the controlled drug receipt showed it had been delivered almost two years ago. The Director of Nursing confirmed that medications should be dated when opened, labels should be legible, and expired medications should be renewed. Both the morphine and diazepam were found to be outdated at the time of the survey. These findings were based on direct observation, staff interviews, and review of medication records, and involved residents with significant medical needs, including palliative care and seizure management.