Failure to Properly Label Resident Medication
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles for one resident reviewed for medication labeling. Specifically, a resident with dementia had a prescription for lorazepam oral concentrate, which was observed stored in the refrigerator inside a plastic baggie. The box containing the medication had a partially illegible label, and the medication bottle itself only had a manufacturer label without any resident or prescription information. Staff indicated they identified the medication by the name on the box, but the bottle itself was not properly labeled. Interviews with facility staff and the pharmacy revealed that the pharmacy required the medication to be returned in order to provide a replacement label, but the facility was unable to send the medication back as it would leave the resident without their medication. The DON stated that the pharmacy could not send replacement labels, and the pharmacist mentioned that the facility could handwrite labels if necessary. Review of facility policy confirmed that the pharmacy was responsible for labeling all dispensed medications.