Failure to Maintain Controlled Medication Records
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not maintaining a system of records for the receipt and disposition of controlled drugs, which is necessary for accurate accounting and to prevent possible diversion. This deficiency was identified during a review of clinical records, facility policy, and staff interviews. Specifically, the facility's policy on Discharge Medications requires that controlled substances not be released upon discharge unless permitted by state law and authorized by the resident's attending physician. Additionally, the policy mandates that a nurse reconcile pre-discharge medications with post-discharge medications and document the reconciliation, including a detailed medication disposition record. In the case of Resident 62, who was admitted with acute cystitis and weakness, there was a failure to document the accountability record for controlled medications, including Oxycodone and Tramadol, upon the resident's discharge against medical advice. The nursing note indicated that the resident signed out against medical advice, and while the attending physician and Nursing Home Administrator were notified, there was no documented evidence of a controlled medication accountability record. The Director of Nursing confirmed the absence of this documentation, which is required by facility policy to prevent unauthorized use and ensure accurate tracking and disposition of controlled medications.
Plan Of Correction
The facility cannot retroactively correct the absence of the medication disposition on resident 62. Residents discharged home in the last 30 days will be reviewed to determine the presence of medication disposition form. Nursing staff will be re-educated on completion of the medication disposition form upon discharge home. Audits will be completed on residents discharging home from the facility to ensure the presence of the medication disposition form weekly x 4 weeks, then monthly x 2 months. Results will be reviewed in monthly QAPI meeting.