Improper Medication Labeling and Storage in Medication Carts
Penalty
Summary
Surveyors identified a failure to ensure medications were properly labeled and securely and orderly stored. During observation of the 200-hallway medication cart, accompanied by QMA 3, a white round pill imprinted TCL 340 and a yellow oblong pill imprinted C55 were found loose in the second drawer from the top of the cart. QMA 3 stated that any loose medications found in the medication cart should be destroyed in the drug buster and that medication carts were cleaned out on an as-needed basis. This cart stored medications for 39 of 51 residents. On the 100-hallway medication cart, accompanied by RN 4, surveyors observed multiple insulin pens and an eye drop bottle that were not labeled in accordance with facility policy and accepted standards. One prefilled disposable insulin glargine pen with approximately 20 units remaining had only a handwritten resident name and an opened date that RN 4 indicated was either expired or possibly written incorrectly, and the pen lacked a proper resident label. A second insulin glargine pen with approximately 25–30 units remaining had a handwritten resident name but no opened date and no label. A bottle of olopatadine 0.2% eye drops labeled for a resident lacked an opened date, and another insulin glargine pen with approximately 150 units remaining had only a handwritten resident name and opened date on the lid, without a resident label on the pen itself. The DON stated that all medications should be labeled with the resident's name, ordering provider, date opened, and expiration date, and the facility’s policy required orderly storage, individual resident compartments, and dating of multi-dose containers when opened.
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