Medication Labeling Inconsistencies and Unsecured Medication Cart
Penalty
Summary
The deficiency involves failure to ensure accurate medication labeling and secure storage of medications. Surveyors observed that an insulin pen for Resident #3 was labeled for Lantus Solostar at 10 units in the morning, while a nurse prepared and administered 12 units, stating the provider had changed the order and that the correct 12‑unit dose was reflected in the electronic medication administration record (eMAR). Review of the eMAR confirmed a 12‑unit Lantus Solostar order with a start date of 11/17/2025. An administrative nurse later confirmed that the insulin pen label did not match the physician’s order in the eMAR and stated that insulin pen labels typically indicate “See MAR for dose,” and she expects staff to follow the eMAR. Facility policy on labeling of medications indicated that when a dose change occurs, pharmacy either sends a “see MAR for orders” label or a new label, and if pharmacy has not yet complied, nursing staff are to continue to administer the correct dose per the physician’s orders in the electronic record. The deficiency also includes failure to keep a medication cart locked when unattended. Surveyors observed a medication cart identified as #700 unlocked and unattended while a staff nurse was down the hallway. On another observation, the same medication cart was again found unlocked and unattended, and it remained so for eight minutes until an administrative nurse walked by and locked it. Review of the facility’s medication administration policy showed that the medication cart is required to be locked at all times when unattended. During interview, an administrative nurse stated she expects staff to lock the medication cart when it is not being attended.
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