Improper Labeling and Administration of Controlled Medications
Penalty
Summary
The facility failed to ensure medications were properly labeled, stored, and administered according to physician orders and facility policy for two residents. One resident with chronic obstructive pulmonary disease, chronic pancreatitis, and generalized anxiety disorder was admitted on 03/21/25 and placed on hospice care on 06/02/25. On that date, the resident was prescribed Lorazepam oral concentrate 0.25 ml every 4 hours as needed for terminal anxiety, but the medication was dispensed and administered in pill form instead of the ordered liquid concentrate. The controlled substance log initiated on 06/02/25 was labeled for Lorazepam 0.5 mg tablets, and documentation showed the resident received the wrong dosage form on multiple dates (06/04/25, 06/05/25, 06/06/25, 06/09/25, and 06/10/25). Additionally, the Lorazepam was discontinued on 06/19/25 but was not removed from circulation, and the resident received an additional dose without a physician’s order on 07/06/25. In a separate incident, a surveyor observed an RN at the medication cart and asked about narcotic administration. The RN presented the narcotic box, where the surveyor observed a morphine bottle with no label identifying the resident, the correct dose, or other required information, only a handwritten “#36” in permanent marker. When questioned, the RN had to search through narcotic records to determine that the bottle belonged to another resident and confirmed that the morphine oral concentration bottle was not properly labeled with the resident’s name, date of birth, pharmacy dispense date, or other identifying information. The RN acknowledged that this morphine had been administered 13 times without proper labeling and stated they had not realized the resident’s name was missing from the bottle. The DON later stated that liquid medications, especially morphine, were expected to be correctly labeled and that unlabeled morphine should not be administered.
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