Failure to Label Multi-Dose Medications on Medication Carts
Penalty
Summary
Surveyors determined that the facility failed to ensure all drugs and biologicals were stored and labeled according to professional standards on two medication carts. During medication passes on the third-floor nursing unit, observations revealed that all over-the-counter multi-dose medications and multi-dose eyedrops stored in the top drawers of two medication carts were not labeled with the date of opening. Specifically, 35 bottles of multi-dose over-the-counter medications and 21 multi-dose eyedrops on one cart, and 34 bottles of multi-dose over-the-counter medications and 10 multi-dose eyedrops on another cart, were found without the required labeling. Interviews with licensed nurses confirmed that it was the responsibility of all nurses working on the medication carts to label multi-dose medications with the date of opening, and acknowledged that this had not been done. The facility's policy requires opened multi-dose medications to be dated and discarded within 28 days unless otherwise specified by the manufacturer, and that only authorized personnel have access to locked medication storage. The observed failure to label these medications constituted noncompliance with both facility policy and regulatory requirements.