Failure to Document Medication Disposition for Discharged Residents
Penalty
Summary
The facility failed to maintain an accurate accounting of the final disposition of medications upon discharge for two residents. For one resident, who was discharged to the hospital, the clinical record showed that 98 Oxycodone tablets remained at discharge. The facility's policy required that the disposal of controlled substances be documented by two staff members, but in this case, only one staff member signed off on the disposal of the medication. This discrepancy was confirmed during an interview with the Director of Nursing (DON). For another resident, who was discharged to home, there was no evidence in the clinical record of the final disposition of the prescribed Oxycodone medication. The facility's policy mandates that the disposal of controlled substances be documented, but the record lacked this documentation. The DON was unable to provide additional information regarding the final disposition of this resident's medications during an interview.
Plan Of Correction
Facility cannot retroactively correct cited deficiency. A Comprehensive review of residents who have been discharged from the facility in the last 30 days will be conducted to ensure that "disposition of medication" form has been completed with 2 Licensed nurse signatures. The facility will take the further steps to ensure that the problem does not re-occur by in-servicing Licensed nursing staff on F Tag 755 with focus on disposition of medications as well as Facility policies, "Disposal of Medication Waste" and "Collection Receptacles for Disposal of Medications". Compliance will be monitored by the Director of Nursing / Designee using the Disposition of Medications audit form to ensure that disposition of medications were completed with 2 nurse signatures. Will review 5 discharged residents weekly x 3 weeks then monthly x 2 months, with audit results being forwarded to the QAA committee to determine the need for further follow up/monitoring.