Failure to Timely Dispose or Reconcile Discontinued Medications
Penalty
Summary
The facility failed to dispose of or reconcile discontinued medications in a timely manner on the Second Floor nursing unit and the Third Floor Medication Room. During an observation, a cardboard box containing various medications and biologicals was found under a desk at the nurse's station on the Second Floor. These included TPN bags, Lovenox syringes, Tuberculin solution, and other medications, some of which were unopened. A Registered Nurse acknowledged the box as containing medications that needed to be disposed of. The Regional Director of Clinical Services confirmed the issue, stating that there was difficulty in determining which medications were returnable to the pharmacy and which needed to be destroyed. On the Third Floor, the Medication Room contained expired medications, including Ampicillin vials connected to sodium chloride bags, Lactated Ringers, and various pills and syringes. A Clinical Quality Specialist confirmed these observations and noted that the pharmacy does not always accept returns, necessitating destruction of the medications. The facility's policy required discontinued medications to be returned to the pharmacy or destroyed within 48 hours, which was not adhered to, leading to the deficiency.
Plan Of Correction
The observed 2nd floor box of medication was returned to pharmacy. The observed medication in the third floor medication room were returned to pharmacy. The Director of Nursing (DON)/designee audited medications rooms to ensure discontinued medications were disposed of or reconciled. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated DON and ADON on the process for medication return/destruction. To monitor and maintain ongoing compliance, the DON/designee will audit medication rooms/nursing stations for medications needing destruction or return to pharmacy 2 x a weekly x 4 weeks, then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.