Failure to Properly Label Medications and Biologicals
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling of medications in both a medication cart and a medication room, potentially affecting 25 residents. During inspection of a medication cart, a box of Ketotifen fumarate ophthalmic solution was found labeled with a resident's name and room number, but the solution bottle inside the box was not labeled with any identifying information. Other single-user bottles and vials in the cart were properly labeled. The LPN present was unsure if it was necessary to label the bottles themselves or if labeling the box was sufficient. In the medication room, a box of Tuberculin Purified Protein Derivative (TB PPD) solution was labeled with an open date, but the vial inside was not. The Clinical Care Coordinator stated she did not label TB vials with the open date, only the box, and expressed uncertainty about what to do if vials became separated from their boxes. Upon further inquiry, she acknowledged learning that vials should be labeled with the open date. A registered nurse later confirmed that vials and bottles in boxes should be labeled with resident names and that TB vials should be labeled with the open date to ensure proper identification if separated from their boxes.