P5280

Failure to Document Timely Medication Disposition

Philadelphia, Pennsylvania Survey Completed on 01-31-2025

Penalty

No penalty information released

Summary

The facility failed to document the timely disposition of medications for a resident, identified as Resident 167, whose clinical record was reviewed during a survey. The facility's policy on medication administration and disposition, dated September 6, 2023, outlines procedures for the timely identification and removal of medications for disposition, storage methods, control and accountability, and documentation of the actual disposition of medications. However, the policy did not provide documented evidence of proper guidelines for the timely and safe identification and removal of medications for disposition as required by 28 Pa. Code:211.9(j) Pharmacy services for discharged residents.

Upon review of Resident 167's clinical record, it was found that the resident had expired on December 12, 2024, but there was no documented evidence indicating that a disposition of medications was completed upon discharge from the facility before the survey began on January 28, 2025. An interview with the Director of Nursing on January 31, 2025, confirmed the absence of documented evidence that the medication disposition for Resident 167 was completed in a timely manner.

Plan Of Correction

This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

The facility cannot go back retroactively to correct the issue.

The DON/designee will audit the last 30 days of discharged residents to ensure timely documentation of medication disposition. Licensed staff were educated on the policy of Medication administration/disposition.

The DON/designee will audit discharged resident records to ensure that the medication disposition assessment is completed timely. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is required.