Failure to Document Medication Disposition for a Resident
Penalty
Summary
The facility failed to document the disposition of medications and the quantity of drugs disposed for one of the three closed clinical records reviewed, specifically for Resident 89. According to the facility's policy for discharge medications, a nurse is required to complete a medication disposition record, which should include the amount or quantity of each medication and the nurse releasing the medication. However, a nursing note for Resident 89 indicated that the resident ceased to breathe, and there was no documented evidence in the clinical record of the disposition of medications or the quantity upon the resident's death. An interview with the Director of Nursing confirmed the absence of this documentation, acknowledging that it should have been recorded.
Plan Of Correction
1. The facility is unable to retroactively correct the disposition of medications for resident 89. 2. Review will be completed of residents discharged 12/15-12/31/24 from the facility or discharged from the hospital to ensure a medication disposition was completed and identified issues will be corrected. 3. The facility discharges will be reviewed at morning clinical meeting to ensure the medication dispositions have been completed. Director of Nursing or designee will educate the RN Supervisors including agency on the medication disposition practice and their responsibility to document the disposition when there is a discharge from the facility. 4. The Director of Medical Records or designee will audit medication disposition on facility discharge weekly for four weeks then monthly for month. Identified issues will be addressed when found. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.