Failure to Properly Label and Store Medications
Penalty
Summary
Facility staff failed to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and manufacturer requirements. In one instance, an opened multi-dose vial of epoetin alfa for a resident was found in the medication room refrigerator without a date indicating when it was first used or when it would expire. The manufacturer's instructions specified that multi-dose vials should be discarded no later than 21 days after first use, and facility policy required the date of opening and expiration to be recorded on the vial. Both the RN and the DON confirmed that the vial was not labeled as required and should have been removed from use, as its effectiveness could not be guaranteed. Additionally, the facility failed to properly label intravenous (IV) ertapenem administered to another resident. The IV bag containing ertapenem, which was prepared from the emergency medication kit, was not labeled with the resident's name or the rate of administration. Facility policy and standard nursing practice require that all medications, especially those from emergency kits, be labeled with the resident's name, medication name, dose, route, date, and rate of administration to ensure safe and accurate medication delivery. The nurse responsible for administering the ertapenem acknowledged that the labeling was incomplete due to being in a hurry, and the DON confirmed that this was not in accordance with facility policy. Both deficiencies were identified through direct observation, interviews with nursing staff and the DON, and review of facility policies and manufacturer instructions. The lack of proper labeling and storage had the potential to result in the use of expired or ineffective medication and could have led to medication administration errors, as the required information to verify the correct resident and administration details was missing.