Failure to Document Controlled Medication Disposal
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 89. The facility's policy on controlled substance disposal required that the destruction or disposal of such drugs be documented on the controlled medication count sheet and signed by a registered nurse and a witnessing licensed professional. However, there was no documentation to indicate that Lorazepam, a controlled medication prescribed to Resident 89, was destroyed or disposed of according to the facility's policy. Resident 89, who was cognitively impaired and had a diagnosis of Metabolic Encephalopathy, was prescribed Lorazepam for anxiety and restlessness. Despite the physician's order for Lorazepam to be administered every four hours as needed, the Medication Administration Record for October 2024 showed no documentation of the medication being administered. Furthermore, after Resident 89 ceased to breathe, there was no record of the controlled drug count or documentation of the medication's destruction. The Director of Nursing confirmed the absence of documentation for the destruction or disposal of Lorazepam.
Plan Of Correction
1. The Pharmacy confirmed Lorazepam was not sent for Resident 76. No medication disposition for destruction would be indicated for a medication not received by facility. 2. A baseline audit was completed to make sure accountability for controlled medications is complete. 3. The Director of Nursing/designee will educate nursing staff including agency on the process of maintaining accountability for controlled medications with corresponding documentation. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks then monthly for two months to make sure accountability is maintained for controlled medications. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.