Failure to Document Medication Disposition
Penalty
Summary
The facility failed to document the actual disposition of medications for three residents, leading to a deficiency in pharmacy services. The facility's policy on medication disposition requires detailed documentation, including the name of the staff disposing of the medication, the resident's name, medication name, strength, prescription number, quantity, method of disposition, and the date of disposition. However, this documentation was missing for three residents: one who ceased to breathe, another who was discharged to home, and a third who did not return from the hospital. Resident CR81, who had diagnoses including metabolic encephalopathy and severe protein calorie malnutrition, ceased to breathe, but the clinical record lacked documentation of medication disposition. Resident CR82, with conditions such as osteoarthritis and pancytopenia, was discharged to home without proper documentation of medication disposition. Resident CR83, who had diabetic ulcers and end-stage renal disease, was transferred to a hospital and did not return, yet the facility failed to document the disposition of their medications. These omissions were confirmed during an interview with the Regional Clinical Consultant.
Plan Of Correction
Resident CR 81, CR 82, CR 83, we were unable to complete a disposition of medications. Residents that were discharged for the last 30 days were for disposition of medications but unable to complete a disposition of medications. Residents discharged, transferred, or ceased to breathe will have a disposition of medication completed. Licensed staff were educated on the disposition of medication policy by the Director of Nursing/designee. Audit will be conducted for those residents who were discharged, transferred, or ceased to breathe weekly for 4 weeks to ensure that disposition of medication on all residents are completed by the Director of Nursing/Designee then monthly for 2 months. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.