Failure to Timely Dispose of Discontinued Medication
Penalty
Summary
The facility failed to dispose of and reconcile discontinued medication in a timely manner for Resident R55. According to the facility's policy on discontinued medications, when medications are discontinued by prescriber order, they should be marked as discontinued and either destroyed or returned to the issuing pharmacy. However, during an observation, a blister pack of Buspirone 7.5 mg, which was discontinued on 12/17/24, was found on a shelf in the medication room on 12/20/24. The blister pack contained 28 pills, indicating that the medication had not been disposed of as per the facility's policy. Resident R55 was admitted to the facility with diagnoses of depression, muscle weakness, and hypothyroidism. The physician's orders indicated that Buspirone 7.5 mg was discontinued on 12/17/24. During interviews, both a registered nurse and the Director of Nursing confirmed that the facility failed to dispose of the medication in a timely manner. This oversight was identified during a review of clinical documentation, observation, and staff interviews.
Plan Of Correction
R55 suffered no ill effects by not having medications disposed of timely. Education on destroying medications will be provided to Nurses by the DON or designee on or before 2/11/2025. Audit of med rooms and carts completed to ensure no other discontinued meds were present. Audits will be conducted on destroyed medications and reconciling of medications weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.