Failure to Properly Label and Store IV Medication
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to ensure that an intravenous (IV) Vancomycin medication administered to a resident was properly labeled in accordance with professional standards and facility policy. During observation, the IV bag in use for the resident did not have a pharmacy label containing the resident's name, medication information, directions for use, administration flow rate, prescriber name, or date of order. The RN acknowledged that the label must have fallen off after hanging the medication and confirmed that all medications are required to have a pharmacy label with the necessary information. The Director of Nursing (DON) also confirmed that all IV medications should be labeled with pharmacy and resident information, as well as directions for use. The resident involved had multiple medical conditions, including COPD, muscle weakness, depression, difficulty walking, a right great toe amputation, a lower left leg open wound, and a peritoneal abscess. The resident also had severely impaired cognition and a history of wandering and removing medical devices. The facility's policy required infusion therapy products to be labeled with specific information to ensure safe administration, but this was not followed in this instance, as observed and confirmed by staff interviews and record review.