Failure to Replace E-Kits and Document Controlled Substance Disposal
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the replacement of portable container non-antibiotic medication Emergency-Kits (E-Kits) within the stipulated 48-72 hours. During an observation and interview, it was found that two E-Kits with red zip ties, indicating they had been opened, were not replaced in a timely manner. One E-Kit had been opened since February 25, 2025, and the other since December 23, 2024, yet neither had been replaced. The Licensed Vocational Nurse (LVN) acknowledged the importance of having the E-Kit available for emergencies to prevent delays in treatment. The Director of Nursing (DON) confirmed the lack of documentation or monitoring logs to ensure E-Kits were checked daily, which could lead to delays in care during emergencies. The facility also failed to implement its policy on the disposal of medications and medication-related supplies, specifically regarding the destruction of controlled substances. During an inspection, it was revealed that 24 resident medications were disposed of without the required signature of a licensed nurse witnessing the destruction. The DON admitted to being the only licensed nurse responsible for the destruction process and failed to sign the Controlled Drug Record sheets due to being occupied with other tasks. This oversight left the destruction process undocumented, raising concerns about potential diversion and theft of medications. The facility's policy indicated that controlled substances should be securely locked until destroyed by a DEA representative or by the facility's DON and/or consultant pharmacist. However, the DON's failure to follow this procedure and the absence of a second signature on the destruction forms compromised the integrity of the medication disposal process. The lack of adherence to these policies placed residents at risk of not receiving necessary medications during emergencies and increased the potential for loss or diversion of controlled substances.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/7/25, the Director of Nursing had the facility's Emergency kit (E-Kit) replaced. There were no negative or adverse outcomes noted related to this deficient practice. On 3/6/25, the Director of Nursing (DON) presented the facility's Controlled Drug Record dated 12/12/2024 without the signature of a licensed nurse witnessing the destruction of the medications. Medication was destroyed in the presence of the Pharmacist. There were no negative outcomes as a result of this deficient practice. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/7/25, the Infection Control Preventionist conducted a visual round to ensure all E-kits were not expired. No other residents were affected by this deficient practice. On 3/19/25, the Medical Records Director conducted an audit on the past quarter of medication destruction sheets. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/12/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), on the facility's policy and procedure titled, "Medication Ordering and Receiving from Pharmacy," undated, with emphasis on emergency needs for medication being met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. The in-service included nursing calling the pharmacy as soon as possible for replacement of the kit/dose and flagging the kit with a color-coded lock to indicate need for replacement of kit/dose. The in-service also emphasized that if exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening, and if replacing used medications, the replacement doses are added to the kit within 72 hours of opening. On 3/12/25, the facility created an E-Kit monitoring log and in-serviced Nursing Staff, including but not limited to LVNs and RNs, on how and when to complete it. The DON/designee will conduct audits daily for five days weekly for two weeks, then monthly for three months to ensure E-kits are not expired and logs are completed for monitoring. On 3/17/25, the facility's assigned Pharmacist from Star Pharmacy in-serviced the Director of Nursing (DON) and Registered Nurse (RN) on the facility's policy and procedure titled, "Disposal of Medications and Medication-Related Supplies," with emphasis on controlled substances being retained in a securely locked area with restricted access until destroyed by a Drug Enforcement Administration (DEA) representative or by the facility director of nursing and/or consultant pharmacist and/or administrator. The in-service also included ensuring signatures of licensed nurses witnessing the destruction of the medications. The Medical Records Director will conduct an audit on the medication destruction sheets monthly and as needed (PRN) to ensure signatures include the signature of a licensed nurse witnessing the destruction of the medications. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for the facility's E-kits not being expired for three months or until compliance is met. The Administrator will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance with medication destruction and disposal, ensuring a signature of a licensed nurse witnessing the destruction of the medications, for three months or until compliance is met.