Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 109 upon discharge. Resident 109 was admitted on November 6, 2024, and discharged on January 29, 2025. However, by the time of the survey, which concluded on April 18, 2025, there was no documented evidence in the resident's clinical record regarding the accounting of remaining medications or their disposition at the time of discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator on April 18, 2025, at 10:30 AM.
Plan Of Correction
P 5280 - Disposition of Medications 1. The facility cannot retroactively correct said deficiency. 2. Residents discharged within the last 14 days will be reviewed by the Director of Nursing or Designee to verify proper documentation for disposition of medications occurred. 3. Director of Nursing or Designee will re-educate licensed nurses on documentation of disposition of medications. 4. Director of Nursing or Designee will conduct audits of discharged residents daily x 2 weeks, weekly x 4 weeks and monthly x 2 months to ensure proper documentation of disposition of medications occurred. Results of these audits will be reviewed by the facility's QAPI Committee for review and recommendations.