Altered Pharmacy Label on Benzonatate Medication Card
Penalty
Summary
Facility staff failed to ensure that a medication label remained unaltered from the pharmacy-printed label for a Benzonatate 100 mg capsule card. During a medication administration observation with an LPN, the Benzonatate medication card was noted to have a handwritten "8" written over the previous hourly instructions for administration, which had indicated intervals such as every 4 hours and every 12 hours. Review of the physician’s order summary showed that the original order for Benzonatate 100 mg was 1 capsule by mouth every three hours PRN for cough, which was then changed to every eight hours PRN for cough, and later changed again to 1 capsule by mouth three times a day for cough for 5 days. Pharmacy instructions indicated that the PRN medication on hand should be used. In an interview, the LPN stated that the order had been changed from PRN to scheduled doses and that the pharmacy had instructed staff to use the on-hand medication until a new medication card was received. The facility’s policy titled “Medication and Medication Labels 3.7” stated that if the prescriber’s directions for use change or the label is inaccurate, the nurse may place a “direction change. Change of order-check chart” or similar label on the container, taking care not to cover important label information. Instead of following this policy, the existing pharmacy label on the Benzonatate card was directly altered by handwriting over the original directions. During a subsequent interview, the DON stated that staff nurses are expected to follow the policy. The survey findings regarding the altered medication label were later presented to the facility’s administrative team, who did not offer comments or concerns.
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