Controlled Substance Labeling Discrepancy
Penalty
Summary
A deficiency occurred when a controlled substance, Morphine Sulfate, was not properly labeled in accordance with the resident's current physician order. During an observation, a surveyor found that the medication label on the resident's Morphine Sulfate bottle instructed administration every 1 hour as needed, while the active physician order specified administration every 4 hours as needed. The LPN confirmed that the label and the active order did not match, and the expectation was for the label to reflect the current order to ensure accuracy in medication administration. The resident involved was cognitively intact and had diagnoses including abdominal pain, restless leg syndrome, and chronic pain syndrome. The medication order had been changed from every 1 hour to every 4 hours as needed, but the label on the medication bottle had not been updated to reflect this change. Facility policy required that medication labels, physician orders, and the MAR be consistent and uniform, and that improperly labeled medications be rejected or returned. However, the outdated label remained on the medication, creating a discrepancy between the label and the current physician order.