Medication Labeling and Administration Time Discrepancy
Penalty
Summary
A deficiency was identified when a bubble pack containing doxazosin 2 mg for a resident was found labeled for administration at bedtime, while the physician's order and the medication administration record (MAR) specified the medication should be given at 9 AM. This discrepancy was discovered during an observation of the medication cart, where a Licensed Vocational Nurse (LVN) noted the mismatch between the label on the medication and the scheduled administration time in the MAR. The resident's medical order, effective since 5/25/2025, clearly indicated the medication was to be administered once daily at 9 AM. Further review revealed that the pharmacy had dispensed the medication with instructions to give it at bedtime, contrary to the physician's order. The Director of Nursing (DON) confirmed that the medication was scheduled for 9 AM and stated that the pharmacy should have communicated any changes to the order. However, there was no documentation or paper trail of such communication from the pharmacy to the facility regarding a change in the administration time. The facility's policy requires that only authorized, licensed practitioners write orders, and that any changes be properly communicated and documented.