Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored in accordance with professional standards for one resident. During an observation of the medication room refrigerator, a zip lock plastic bag was found with a prescription sticker for Lispro insulin, but the bag actually contained a box labeled for Novolog insulin, which was not prescribed to the resident. The Novolog medication was not from the facility's pharmacy, and the packaging indicated a different expiration date than the prescription sticker. Record review confirmed that the resident was only prescribed HumaLOG (Insulin Lispro) and not Novolog (insulin aspart) while at the facility. Interviews with nursing staff and the DON revealed that medications should only be stored in the packaging in which they are received, and that expired or discontinued medications should be removed and either destroyed or returned to the pharmacy. The staff acknowledged that placing a medication box for one drug in packaging labeled for another could lead to medication errors. Facility policy also requires that drugs with missing, incomplete, improper, or incorrect labels be returned to the pharmacy for proper labeling before storage, and that discontinued or outdated drugs be removed.