Unlabeled and Undated Topical Medication Found in Medication Cart
Penalty
Summary
A tube of Triamcinolone Acetonide External Cream 0.5% was found in a medication cart without a label indicating the resident's name or the date the medication was opened. This medication belonged to a resident who had been admitted with type 2 diabetes and a history of falls, and who had moderate cognitive impairment. The physician's order for this medication specified its use for a rash, to be applied topically every 12 hours as needed. During an observation of the medication cart with an LVN, the unlabeled and undated tube was discovered. The DON confirmed that the medication belonged to the resident and acknowledged that all medications in the cart should be labeled and dated, with pharmacy labels including resident information. The facility's policy required all medications to be labeled and dated in accordance with state and federal regulations, including specific information such as the resident's name, prescribing physician, medication details, and appropriate instructions.
Plan Of Correction
F761 - Label/Store Drugs and Biologicals How Corrective Action(s) will be accomplished for those residents found to have been affected by the deficient practice: - On 5/29/25, the Licensed Vocational Nurse (LVN1) removed the Triamcinolone Acetonide External Cream 0.5% in the medication cart. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: - On 6/16/25 and 6/17/25, the Director of Staff Development (DSD) and Quality Assurance Nurse (QAN) conducted a medication cart check to ensure medications stored were labeled accordingly and not expired. (Exhibit #24) - No other residents affected by the same deficient practice. What measures were put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: - On 6/17/25 and 6/18/25, the Director of Nursing (DON) provided in-services to the active licensed nurses regarding the facility's policy and procedure (P&P) titled "Labeling of Medications and Biologicals" dated 12/19/2022. (Exhibit #25) - Beginning on 6/16/25, the QAN and DSD will conduct medication cart checks weekly for three months to ensure medications stored were labeled accordingly and not expired. (Exhibit #26) - Starting on 6/17/25, the QAN will report to the administrator for any noncompliance. How the facility plans to monitor its performance to make sure that solutions are sustained: - The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system. - The QAN will discuss any trends or patterns during the monthly QA committee meeting for three months for review and recommendation and will re-evaluate if any further concerns are identified after. Date of completion: June 20, 2025 F 761