Failure to Document Medication Disposition Upon Resident Discharge
Penalty
Summary
The facility failed to adhere to its own policy regarding the disposition of medications upon a resident's discharge. Specifically, the facility's policy mandates that upon a resident's discharge or leave of absence, their medications should be immediately removed from the medication cart, and any unused medications should be disposed of. The method of disposition and the quantity of the drugs are required to be documented on the resident's chart using the Medication Disposition/Destruction Form. However, in the case of Resident 84, who was admitted on September 5, 2024, and discharged on September 24, 2024, there was no documented evidence of the accounting or disposition of any remaining medications. The deficiency was confirmed during an interview with the Director of Nursing (DON) on December 12, 2024, who acknowledged the lack of documentation regarding the disposition of Resident 84's medications. This oversight indicates a failure in the facility's process to ensure proper control and accountability of medications awaiting final disposition, as required by their policy and regulatory standards.
Plan Of Correction
Resident 84 has been discharged. To identify residents with the potential to be affected, the DON/designee will audit discharges within the last 5 days to ensure medication dispositions are complete. To prevent re-occurrence, the DON/designee will educate licensed nursing staff on the medication destruction/return process. To monitor and maintain compliance, the DON/designee will audit 5 discontinued/returned medications weekly for 4 weeks, then monthly for 2 months. All results will be brought to the QAPI committee.