Medication Labeling and Storage Deficiencies on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were labeled and stored according to professional standards on two of three medication carts reviewed. On the 200-hall east cart, a resident's furosemide package had a pharmacy label with blood pressure parameters that did not match the physician's order, potentially leading to confusion during administration. The nurse interviewed was unsure about the correct parameters and stated he would contact the pharmacy or provider if uncertain. Additionally, on the 200-hall west cart, a resident's allopurinol package did not have an updated label or change direction sticker to reflect a new dosage order, and the nurse was unsure if such stickers were available, though the DON confirmed they were. Further, the 200-hall west medication cart was found unlocked and unattended while the nurse was in a resident's room, contrary to facility policy and medication pass competency requirements. The DON confirmed that medication carts should be locked when unattended to prevent unauthorized access. Facility policy also requires that medication carts not be left unlocked or unattended in resident care areas. These lapses in labeling and storage practices were directly observed and confirmed through staff interviews and record reviews.