Unlabeled Loose Pills Found in Multiple Medication Carts
Penalty
Summary
Surveyors observed that three of eight medication carts in the facility contained loose, unlabeled pills in the drawers. Specifically, the 200 hall nurse cart had two unlabeled pills, the 200 hall medication aide cart had one unlabeled pill, and the 400 hall medication aide cart had four unlabeled pills. These pills were not labeled in accordance with professional guidelines, and staff interviewed acknowledged that the identity of the pills was unknown and that they would dispose of them due to safety concerns. Interviews with nursing and medication aide staff confirmed that the presence of loose, unlabeled pills could lead to contamination, medication errors, or the possibility that a patient might not receive their prescribed medication. The Director of Nursing also stated that loose pills could be accessed by unauthorized individuals and should be destroyed. The facility's policy requires medications and biologicals to be labeled according to facility, state, and federal requirements, which was not followed in these instances.