Failure to Secure Medications and Ensure Accurate Medication Labeling
Penalty
Summary
Facility staff failed to ensure that medications and resident information were secured at all times. During an observation, a medication cart was left unattended and unlocked in a hallway, with the computer screen displaying a resident's identifying information. On top of the cart, there was a cup containing a clear liquid and a medication cup with three white pills. No staff were present in the hallway, and a resident in a wheelchair passed by the unattended cart. The trained medication assistant (TMA) later returned to the cart after assisting with a resident transfer, confirming that the cart and computer screen had been left unsecured with medications exposed. Additionally, the facility did not ensure that medication labeling was clear and unaltered. A resident with multiple sclerosis had a provider order for Baclofen with specific dosing instructions, but the medication bottle label did not match the current order. The label on the bottle was outdated and had handwritten instructions to refer to the electronic medication administration record (EMAR), but there was no required orange sticker indicating a direction change. The TMA was unaware that incorrect doses had been administered over several days due to the mismatched label and lack of clear instructions. The TMA also found half pills in the bottle, which should not have been present, indicating ongoing medication administration errors. The director of nursing confirmed that the Baclofen dose had been changed, but staff continued to use a bottle with an incorrect label after running out of the correctly dosed medication. The facility's policy required that medication labels be neat, legible, and only changed by the pharmacy, but this was not followed. The failure to secure medications and resident information, as well as the lack of proper medication labeling and administration, resulted in multiple medication errors for the resident.