Improper Labeling and Storage of Controlled Medication
Penalty
Summary
The facility failed to ensure that medications were properly labeled in accordance with professional standards and facility policy. During a reconciliation of controlled substances, surveyors observed that a resident's oxycodone tablets were stored in pill-crusher pouches inside a disposable water cup, with the cup labeled only with the resident's name and medication name written in marker. The pouches themselves lacked any pharmacy label or proper identification, containing only handwritten initials and the number '30'. The staff were unable to verify the exact contents or quantity of the medication in the pouches, and the Director of Nursing confirmed that there was no way to know what the tablets actually were or how many were present, aside from the five tablets remaining in the original prescription bottle. The resident involved had a history of osteoporosis, spinal stenosis, chronic pain, osteoarthritis, and joint pain, and had been prescribed oxycodone 5 mg as needed for pain. The medication policy required that drugs be stored in their original packaging with complete pharmacy labeling, and only the dispensing pharmacy was authorized to transfer or relabel medications. The observed practice of storing and labeling the medication did not comply with these requirements, as the medication was not in its original container and lacked the necessary identifying information.