Failure in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to implement proper pharmacy procedures for the reconciliation of controlled drugs, specifically concerning a resident who had ceased to breathe. The facility's policy on the disposal and destruction of expired or discontinued medications requires that such actions be documented on the controlled medication count sheet and signed by a registered nurse and a witnessing licensed professional. Additionally, discontinued and unused medications of discharged or deceased residents should be immediately removed from the medication cart and brought to nursing supervisory staff. However, in the case of a resident who was admitted on June 21, 2010, and had a physician order for morphine solution to be administered as needed, the facility did not adhere to these procedures. The resident, who had diagnoses of Alzheimer's Disease, dementia, and depression, ceased to breathe on December 19, 2024. Despite this, the Controlled Medication Utilization Record indicated that the morphine's "Date of Disposition" was recorded as December 22, 2024, three days after the resident's death. This discrepancy was confirmed during an interview with the Regional Director of Clinical Services, who acknowledged the facility's failure to implement the required pharmacy procedures for the reconciliation of controlled drugs.
Plan Of Correction
Resident #96 closed record reviewed, and the facility cannot retroactively correct reconciliation of controlled drugs. There were no other concerns identified regarding reconciliation of controlled medications during survey. To identify other residents that have the potential to be affected, the DON/designee completed an audit of medication destruction logs for closed records of all residents that discharged at time of exit (1/16/2025 to current) with no negative findings. To prevent this from recurring, the DON/designee educated licensed nursing on medication destruction in compliance with Disposal/Destruction of Expired or Discontinued Medication. To monitor and maintain ongoing compliance, the DON/designee will complete medication destruction audit weekly x4 then monthly x2 to ensure medication disposal/destruction and reconciliation is completed appropriately. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.