Improper Labeling and Storage of Medications and Supplements
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals for two residents. For one resident, multivitamin supplements were stored in the medication cart with only the room number as an identifier, lacking the resident's name and date of birth. Both a registered nurse and a licensed vocational nurse confirmed that supplements and medications should be labeled with the resident's name and date of birth, as per facility practice, to prevent potential mix-ups if a resident is moved to another room. For another resident, a box containing morphine sulfate solution was found in the medication cart with a medication label belonging to a different, previously discharged resident. A licensed vocational nurse acknowledged that this labeling error could lead to medication errors. The facility's policy requires that all medications, including nonprescription items, be labeled with the resident's name and that containers with confusing or incorrect labels be returned to the pharmacy or destroyed.