Medication Labeling Error for Potassium Chloride
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a medication label was accurate for a resident. Review of the resident's physician orders showed an order for Potassium Chloride Liquid 20 MEQ/15ML to be given once daily via PEG-tube for hypokalemia. However, observation of the medication label revealed it was incorrectly labeled as Potassium Chloride Liquid 20 MEQ/7.5 ML. An interview with the DON confirmed that the pharmacy had mislabeled the medication, instructing administration of 7.5 ML instead of the ordered 15 ML.