Improper Labeling and Dating of Multi-Dose Medications
Penalty
Summary
Surveyors identified a failure to ensure multi-dose medications were labeled and discarded according to manufacturer and pharmacy instructions in one of two medication rooms reviewed. During an observation of the second-floor medication room with a registered nurse, an open bottle of Latanoprost ophthalmic solution for a resident with primary open-angle glaucoma was found with an open date of 08/01/2025, despite the pharmacy label directing that any remaining drug be discarded 6 weeks after first use. The resident’s order for Latanoprost had been in place since 2019. Additionally, an insulin lispro vial for a resident with type 2 diabetes mellitus was found without an open date, even though the pharmacy label instructed that any remaining medication be discarded 28 days after first use. Further observation in the same medication room revealed two open, undated vials of Tuberculin Purified Protein Derivative. The vial label stated that once entered, the vial should be discarded after 30 days, and accompanying medication literature specified that vials in use more than 30 days should be discarded due to possible oxidation and degradation affecting potency. In an interview, the registered nurse confirmed that all multidose medications and vials should be labeled with an open date once opened. Review of the facility’s “Storage of Medications” policy showed that medications and biologicals are to be stored safely and properly, and that when the original seal of a manufacturer’s container or vial is initially broken, the container or vial must be dated, including for multi-dose injectables and ophthalmic medications or items with a specified usable life after opening.
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