Improper Prefilling and Labeling of Medication Cups During Night Shift Med Passes
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored, prepared, and administered in accordance with professional standards and facility policy. Photographs reviewed by surveyors showed one image with fourteen medication cups containing pills, stacked on top of each other and unlabeled, and a second image with nine empty, unlabeled medication cups lined up on a medication cart. These photos were associated with an LPN’s medication passes on two different halls during the night shift. The DON, upon viewing the photos, confirmed that the cups in both images were unlabeled and, in the first image, stacked with pills already placed in them. Interviews with two residents indicated that an LPN on the night shift was preparing medications ahead of time without labeling the cups and stacking them. An interview with a confidential individual confirmed that the photographs were taken during the identified LPN’s medication passes on the 100 and 200 halls. The facility’s pharmacist stated that medications are not to be prefilled ahead of time, stacked, or left unlabeled, and that medications are to be administered one resident at a time. Review of the facility’s “General Dose Preparation and Medication Administration Policy” likewise showed that staff are to prepare medications for only one resident at a time. This conduct had the potential to affect all 47 residents residing on the 100 and 200 halls and was cited under a complaint investigation.
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