Failure to Properly Label Medications in Medication Room and Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling of medications in both the medication room and two medication carts. Specifically, an inhaler belonging to one resident was found in the medication room without a resident or pharmacy label. Additionally, multiple residents' eye drops and a controlled medication (liquid morphine sulfate) were found in medication carts without appropriate labeling. Staff interviews confirmed that all medications, including inhalers, eye drops, and controlled substances, were expected to have pharmacy or resident labels to ensure correct administration. During observations, staff members, including the DON, LVN, and RN, acknowledged that the lack of labeling could prevent accurate identification of medications, especially when multiple residents were prescribed similar drugs. The staff stated that it was the pharmacy's responsibility to provide labels, and the nursing staff were expected to notify the pharmacy if a medication was found without a label. The pharmacist in charge also confirmed that all medications should be labeled and that the process had not been followed for the medications in question. A review of facility policies indicated that all prescription drugs must be labeled and that medication administration procedures require verification of resident name, medication name, form, dose, route, and time. The DON confirmed that the facility had not adhered to its own medication labeling policies for the affected residents, resulting in the observed deficiencies.