Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of medications for nine residents. Medications, including eye drops, insulin pens, inhalers, and nitroglycerin, were found without proper labeling, such as missing resident names, administration directions, or dates of opening. In several cases, medications brought in by families lacked pharmacy labels, and staff relied on electronic medication administration records (EMAR) for instructions rather than ensuring the medication containers themselves were properly labeled. Some medications, such as eye drops and insulin pens, were not dated when opened, making it difficult to determine if they were still within the manufacturer’s recommended usage period. Observations revealed that staff did not consistently follow procedures for labeling medications upon opening or for maintaining medications in their original packaging with pharmacy labels. For example, eye drops and insulin pens were found undated, and some medications were stored outside of their labeled boxes, resulting in missing instructions and resident identifiers. Staff interviews confirmed that the expectation was to label medications with the date opened and to dispose of them after the recommended period, but this was not consistently practiced. In some instances, staff removed and destroyed improperly labeled or expired medications during the survey. The facility’s own policy required that all medications be labeled with the medication name, prescribed dose, strength, expiration date, resident’s name, route of administration, and instructions. However, the survey found that this policy was not followed for several medications, including those for dry eyes, glaucoma, diabetes, and chest pain. The lack of proper labeling and storage was confirmed by nursing staff, the clinical coordinator manager, the consultant pharmacist, and the director of nursing during interviews and observations.