Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. On one medication cart, the narcotic count sheets were not verified for the current day, with the last entry recorded the previous night. The Assistant Director of Nursing (ADON) confirmed that narcotic counts should be performed and documented at each shift change, but the responsible LPN had not completed the count and cited the absence of a log sheet as a possible reason. Additionally, another LPN admitted to not having counted narcotics that day. Further observations revealed that a resident was administered Meloxicam 7.5 mg, which had been discontinued per physician orders and replaced with a 15 mg dose. The discontinued medication remained in the cart alongside the new medication, and the LPN acknowledged the error after reviewing the orders. Another issue was found with an insulin pen in a medication cart that was in use but lacked an open date, which the LPN attributed to forgetting to date it. Audits performed by the ADON and Unit Manager (UM) focused on medication administration and storage, but the UM reported not regularly checking for discontinued medication cards, and insulin pens were not always dated upon opening.