Failure to Verify Medication Labels During Discharge
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents, specifically in ensuring the accurate receiving and dispensing of medications. During the discharge process, a resident with diagnoses including diabetes mellitus and dependence on renal dialysis was sent home with another resident's Novolog insulin pen. The LPN responsible for the discharge removed insulin pens from a bag labeled with the resident's identification sticker but did not verify the labels on the actual medication inside the bag. The Director of Nursing confirmed that the nurse should have checked the medication labels and was unsure whether the error originated from the pharmacy or from staff placing the medication in the wrong bag. A review of the facility's discharge planning policy revealed that it did not require staff to confirm medication labels when providing discharge medications to residents. This oversight contributed to the error, as staff relied solely on the external bag label rather than verifying the medication itself. The incident was identified during interviews and record reviews, highlighting a lapse in procedures intended to ensure residents receive the correct medications upon discharge.