Unlabeled, Unordered Nasal Spray Left at Resident Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were stored and labeled according to professional standards and facility policy for one resident. Facility policy required that medications and biologicals be stored in locked compartments, that only the issuing pharmacist authorize transfer of medications between containers, that medications be stored in an orderly manner with each resident’s medications assigned to an individual area, and that labels include the medication name, prescribed dose, strength, expiration date when applicable, resident’s name, route of administration, and appropriate instructions and precautions. The policy also specified that only the dispensing pharmacy may label or alter the label on a medication container or package. Resident R1, who was cognitively intact per a BIMS score of 15 and admitted with a diagnosis of acute respiratory failure, was observed to have a full bottle of Fluticasone Propionate nasal spray on the bedside table during a unit tour. The bottle did not have a label with the resident’s name, and review of the physician’s orders showed no order for Fluticasone Propionate nasal spray for this resident. The resident reported that the physician had given the nasal spray the previous day. The ADON and a licensed nurse confirmed that the unlabeled Fluticasone Propionate nasal spray was present at the bedside and that there was no physician’s order for it. A follow-up observation with the DON again found the same unlabeled, full nasal spray bottle at the bedside, confirming that the medication was not stored in a locked compartment and was not labeled in accordance with facility policy and professional standards.
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