Improper Storage and Labeling of Zyprexa Doses
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for a resident with multiple mental health diagnoses, including unspecified psychosis, major depressive disorder, and schizoaffective disorder, bipolar type. During a medication pass observation, it was found that Zyprexa 5 mg and Zyprexa 10 mg tablets were mixed together in the same plastic bag, which was labeled only for the 5 mg dose. The medication administration record indicated that the resident was prescribed Zyprexa 5 mg in the morning and Zyprexa 10 mg in the evening, with each dose intended to be administered separately. The licensed vocational nurse (LVN) administering the medication was unaware of who had placed both doses in the same bag and acknowledged that the medications should have been stored separately. Interviews with the LVN and the Director of Nursing (DON) confirmed that the practice of mixing different doses of Zyprexa in one bag was improper and could lead to medication errors. The DON reviewed a photograph of the mixed medications and stated that the medications should have been separated, with the 10 mg dose stored in the medication cart for evening administration. The facility's policy and procedure on medication storage required segregation and proper labeling of medications, which was not followed in this instance.