Failure to Document Medication Disposition for Deceased Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 110, who expired at the facility on November 19, 2024. A closed clinical record review revealed that there was no documented evidence regarding the disposition of several medications prescribed to Resident 110. These medications included Atorvastatin, Cyanocobalamin, Insulin Glargine, Melatonin, Metoprolol Succinate, Pantoprazole Sodium, Magnesium Oxide, Metformin HCL, and Ranolazine. The deficiency was identified based on a closed clinical record review and staff interview, which confirmed the lack of documentation in the clinical record upon the resident's discharge. The facility's failure to document the disposition of these medications is a violation of the regulation requiring control and accountability of medications awaiting final disposition, as well as proper documentation of the actual disposition of medications.
Plan Of Correction
1. A disposition of medication for resident 110 cannot be retroactively produced. 2. An audit will be completed of residents who have discharged from the facility from January 6, 2025, to January 13, 2025, to ensure that a disposition of medication is completed upon discharge. 3. Education will be provided to licensed nursing staff on ensuring a disposition of medication is completed upon resident discharge. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months on residents who have discharged from the facility to ensure disposition of medication is completed. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.