Mislabeled Sertraline Blister Pack Not Updated to Match EMAR Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically on one medication cart used by a medication aide. For one resident, a male with a history of anxiety and major depressive disorder and severe cognitive impairment (BIMS score of 4), the physician’s order and EMAR reflected a current dose of Sertraline 125 mg daily, consisting of a 100 mg tablet plus a 25 mg tablet. The resident’s care plan directed nursing staff to administer Sertraline as ordered by the physician, and the MAR for the month confirmed that the resident had been receiving 125 mg per the current order. However, during observation of the medication cart, the blister pack label for the resident’s Sertraline 100 mg still instructed staff to give one 100 mg tablet with a 50 mg tablet for a total dose of 150 mg, which did not match the current EMAR instructions. During interviews, the medication aide stated that medication aides and nursing staff were responsible for updating blister pack labels to match the EMAR, and that she had been trained to notify the floor nurse when blister pack instructions and EMAR orders did not match so the nurse could reconcile the medications. She also stated she was trained to add a label directing staff to refer to the EMAR for the most current physician orders, and that she audited her cart one to two times per week, while nurses also audited carts but she was unsure of their frequency. The medication aide acknowledged she failed to update the Sertraline label earlier in the week because she became distracted with other duties and could not recall the last in-service on medication labeling. The DON confirmed that medication aides were responsible for updating blister packs to reflect EMAR instructions, that a red sticker was used to direct staff to the EMAR, and that medication aides audited carts weekly with nurses auditing less frequently, though she could not provide a specific timeframe or recall the last in-service. The facility’s medication storage policy referenced random quality assurance checks and corrective action when problems are identified, but did not prevent the mislabeled Sertraline blister pack from remaining on the cart.
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