Failure to Properly Label Individual Medication Containers
Penalty
Summary
During an inspection of the Southwest Medication Cart, surveyors observed that medications were not appropriately labeled in accordance with professional standards. Specifically, a box of Desmopressin Nasal Spray and a box of fluticasone and salmeterol were found with the respective residents' names on the outer boxes, but the individual nasal spray container and diskus inside the boxes were not labeled with any identifying information. This created a situation where, if the medication containers became separated from their boxes, it would not be possible to identify which resident they belonged to. Interviews with nursing staff confirmed that the standard practice is to label individual medication containers with the resident's name, either using pharmacy-provided labels or by writing the name directly on the item. Staff members acknowledged the importance of this practice, especially when multiple residents are prescribed the same medication, to prevent mix-ups. However, in these instances, the labeling procedure was not followed, resulting in a failure to ensure that all drugs and biologicals were properly labeled as required.