Improper Disposal of Controlled Medications
Penalty
Summary
The facility failed to properly dispose of controlled medications in accordance with its policy, which led to a deficiency. The policy, last reviewed in January 2025, requires that unused medications be destroyed in a manner that renders them unfit for human consumption, using a Drug Buster device, and witnessed by a second licensed nurse. However, during a medication pass, a registered nurse (RN 1) was observed removing a fentanyl patch from a resident with nerve pain and disposing of it in a syringe disposal container without a witness. This action was confirmed by the Director of Nursing as not adhering to the facility's policy.
Plan Of Correction
DON reeducated RN 1 immediately upon learning of the improper disposal and failure to obtain second witness signature per facility policy. Resident audit conducted - no other residents with fentanyl patch orders. DON and/or nursing supervisor will provide reeducation to licensed nurses on proper disposal of fentanyl patches and need for signature witness per facility policy. DON or designee will conduct routine audits to verify compliance with proper disposal of fentanyl patches. Audit will be conducted weekly for the first 4 weeks and then monthly. Audit results will be reviewed during the monthly Quality Assurance Committee Meetings.