Failure to Update Medication Label Following Order Change
Penalty
Summary
A deficiency was identified when a medication cart in the 300 Hall was found to contain a package of sertraline for a resident with a label indicating a dosage of 50 mg, along with instructions to give one tablet daily with an additional 100 mg to equal 150 mg. However, the current physician order for the resident was for sertraline 50 mg, one tablet by mouth daily, with no end date. During medication administration, the medication aide administered only 50 mg of sertraline to the resident, in accordance with the current order, but the medication package still displayed outdated instructions referencing the previous 150 mg dosage. The facility's policy requires that when there is a change in a physician's order, a direction change sticker or equivalent must be affixed to the medication label to alert staff to the updated instructions. In this case, the required change direction label was not present on the medication package, and the Director of Nursing confirmed that staff should have placed the sticker to prevent confusion and ensure the correct dosage was administered. This lapse in labeling could have led to medication errors, as the medication label did not reflect the current physician order.