F0761

D

Improper Medication Storage and Labeling on Medication Cart

Byram, Mississippi Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s medication storage and labeling practices involving one of three medication carts, specifically the 400 Hall medication cart. The facility’s written policy on medical supply storage, dated March 2011, did not address the practice of storing one medication inside the packaging of another medication. A Medication Error Report dated 12/29/25 documented that individual Restasis vials were found inside a nebulizer medication box, and a family member reported that the wrong vial had been brought into a resident’s room. The Administrator stated he expected nurses to maintain accurate storage of medications to ensure safe administration and acknowledged that storing one medication in the box of a different medication could lead to administration of the wrong medication.

The DON confirmed that on 12/29/25 she was notified by the family of a resident that a nurse had entered the resident’s room with an incorrect vial for a nebulizer treatment. During her investigation, she found multiple vials of Restasis eye drops stored inside an Albuterol Sulfate Inhalation Solution package labeled with the resident’s name. The resident involved had been admitted with diagnoses including cerebral infarction (stroke) and dysphagia, and an MDS assessment dated 11/12/25 documented that the resident was rarely or never understood and had severely impaired cognitive skills for daily decision making. The resident’s representative reported that when the nurse entered the room and announced she was going to administer a nebulizer treatment for congestion, the representative observed that the vial was obviously not the correct medication and pointed this out, after which the nurse left the room without placing the medication into the nebulizer unit.