Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to medication management and storage. During a medication administration observation, a nurse was found to have left a tray of prepared medications unattended at a resident's bedside on several occasions while retrieving additional items such as a straw, spoon, and tissue paper. The resident was in bed with a family member present, and the medications, including a nasal spray, were left unsupervised each time the nurse left the bedside. Additionally, the nurse was observed leaving the medication cart unlocked and unattended in the hallway while entering the nurses' station, with non-licensed staff passing by. Further review revealed that the label on a bubble pack of losartan did not match the current physician's order. The label instructed to hold the medication if the systolic blood pressure (SBP) was more than 130 mmHg, while the physician's order specified to hold if SBP was less than 130 mmHg. The nurse confirmed the discrepancy and acknowledged that a change of direction sticker had not been placed on the medication packaging. Facility policies required accurate labeling and secure storage of medications, but these were not followed in the observed instances.