Failure to Properly Label Resident Medication Following Order Change
Penalty
Summary
The facility failed to ensure that medications were properly labeled for one resident. According to the facility's policy, all medications and biologicals must be labeled in accordance with state and federal regulations, including appropriate instructions and precautions. For one resident, physician's orders indicated a specific dosing schedule for Gabapentin, requiring two 300 mg capsules daily and one 300 mg capsule at bedtime. However, during a medication administration observation, it was found that the label on the resident's blister pack for Gabapentin did not match the current physician's orders. The blister pack label instead indicated a different dosing schedule, with one 300 mg capsule daily and two 300 mg capsules at bedtime. An interview with the LPN administering the medication confirmed the discrepancy between the medication label and the resident's current orders. The LPN also acknowledged that a "change in direction sticker" should have been present on the blister pack to alert staff to the updated orders. The DON further confirmed that the absence of this sticker was a failure to follow proper labeling procedures, as required by facility policy and regulations.
Plan Of Correction
R37 medication label was corrected immediately at the time of survey. R37 no longer resides at facility. Re-education will be conducted by the Director of Nursing for all licensed staff on the need to ensure that any labels needed for medication direction change are put onto the medication card. Medication direction change orders were reviewed to ensure all previous direction changes are correct on the medication labels. Medication change orders will be reviewed daily during Morning Meeting (M-F) and labels verified for accuracy by the Director of Nursing or designee. A pharmacy representative will be included in the ongoing audits and will assist with audits of the medication change orders and medication labels during monthly reviews. The audit outcomes will be presented to the Quality Assurance Committee for review and recommendations.