Failure to Update Medication Labeling for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that medication labeling practices were accurately followed for a resident prescribed amlodipine, a blood pressure medication. During a medication administration observation, it was found that the label on the resident's bubble pack for amlodipine did not match the current Medication Administration Record (MAR). The bubble pack label instructed staff to hold the medication if the resident's systolic blood pressure (SBP) was greater than 110 mm Hg, while the MAR correctly indicated to hold the medication if the SBP was less than 110 mm Hg. This discrepancy was confirmed during interviews and record reviews with nursing staff, who acknowledged that the label should have been updated to reflect the new physician order and that the process for addressing such discrepancies was not followed. Further investigation revealed that the pharmacy had sent a fax to the facility to clarify the order and received the corrected hold parameter from the facility. However, due to insurance constraints, a new bubble pack with the correct label could not be sent immediately. The pharmacy's established process required the facility to place a 'change in direction' sticker on the existing bubble pack to alert staff to the updated order, but this step was not taken. Both the consultant pharmacist and pharmacy supervisor confirmed that the failure to apply the sticker represented a breakdown in the process and could have led to medication administration errors. A review of the facility's policies indicated that staff are required to reconcile medication labels with current orders, communicate any changes to the pharmacy, and use a 'change in direction' sticker when waiting for updated packaging. The failure to follow these procedures resulted in the medication label remaining inconsistent with the MAR and the physician's order, creating the potential for the resident to receive the medication incorrectly.