Failure to Document Controlled Medication Disposal
Penalty
Summary
The facility failed to maintain accountability for controlled medications for two residents. For one resident, the facility's policy required that two licensed nurses witness and document the disposal of fentanyl patches. However, there was no documented evidence that two staff members signed off on the destruction of the old fentanyl patches on multiple occasions. The Director of Nursing confirmed the lack of documentation for the destruction of the patches. For another resident, who was discharged to another nursing facility, there was no documented evidence of the disposition of Ativan, a controlled drug, upon discharge. The Assistant Nursing Home Administrator confirmed the absence of documentation regarding the medication's disposition. These deficiencies indicate a failure to adhere to the facility's procedures for managing controlled substances, as required by regulations.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility could not go back and fix Resident #44 destruction log. The facility could not go back and fix the accountability log for Resident #149 narcotic at time of discharge. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit Fentanyl destruction logs for the last 30 days to ensure two signatures are present and review residents discharged over the last 2 weeks to ensure accountability of narcotics if resident was to be discharged with them. To prevent a future occurrence, the Director of Nursing/designee will educate licensed nursing staff on the proper destruction of medications and medication disposition of discharged residents. To monitor and maintain ongoing compliance, the Director of Nursing/designee will audit Fentanyl destruction logs and accountability of narcotics on discharge weekly x4 and then monthly x2 to ensure two signatures are present and residents are discharged with narcotics if ordered by Medical Director (MD). Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.