Failure to Secure Medications and Ensure Accurate Pharmacy Labeling
Penalty
Summary
The facility failed to ensure that medications were secured when unattended and that pharmacy labels matched physician orders for a resident with multiple diagnoses, including stage 4 pressure ulcers and hypertension. During medication administration, an LPN was observed leaving a cup containing a white powder (Miralax) unattended on top of the medication cart while attending to other tasks, including assisting a resident and checking the kitchen menu. Both the LPN and the Director of Nursing confirmed that medications should not be left unattended on the medication cart. Additionally, a discrepancy was found between the physician's order and the pharmacy label for the resident's Oxycodone prescription. The physician's order specified 0.5 tablet by mouth twice daily, both scheduled and as needed, while the pharmacy label indicated 0.5 tablet by mouth four times daily as needed. The LPN acknowledged the mismatch and stated that an order change sticker should be used, but none was present. The Director of Nursing confirmed that pharmacy labels should match physician orders and that a new card should be dispensed when orders change.