Failure to Remove and Destroy Discontinued Controlled Medications
Penalty
Summary
The facility failed to ensure that completed or discontinued controlled medications were promptly removed from medication carts and properly destroyed, as required by federal regulations and facility policy. During observations and interviews, surveyors found that controlled medications, specifically Ativan 0.5 mg tablets, remained in the medication carts for two residents after the medications had been discontinued or completed. In one instance, a nurse confirmed that a bubble pack containing forty Ativan tablets for a resident with a history of radiculopathy, convulsions, and muscle spasm was still present in the cart, despite the medication order having ended weeks prior. The nurse acknowledged that the medication should have been surrendered to the DON for destruction. A similar situation was observed with another resident diagnosed with dementia, psychotic disturbance, and pain. Two bubble packs of Ativan, containing a total of thirty tablets, were found in the medication cart, even though the medications had been completed the previous year. The nurse responsible for the cart confirmed that the medications should have been removed and given to the DON for destruction, and acknowledged that keeping discontinued controlled medications in the cart was unsafe. Interviews with the DON and the pharmacy consultant confirmed that the facility's policy requires discontinued or completed controlled medications to be immediately removed from medication carts, documented, and stored securely until destruction. Record reviews corroborated that the medications in question had not been administered for several months, yet remained accessible in the carts. The facility's failure to follow its own procedures and federal requirements resulted in the presence of unused controlled substances in medication carts, as directly observed by surveyors.
Plan Of Correction
F755 Pharmacy Srvcs/Procedures/Pharmacist/Records How the corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: a) Resident #8 and Resident #59 discontinued medications were removed from the cart immediately on 04/09/2025. How the facility will identify other residents having the potential to be affected by the same deficient practice and what action will be taken: b) An audit of all medication carts was completed on 05/01/2025 by Nurse Supervisor to ensure all discontinued medications were removed from the cart and logged for destruction. All residents have the potential to be affected by this deficient practice. No other residents were identified to have this same deficient practice. What measures will be put into place or what systemic changes you will take to ensure that the deficient practice will not recur: c) In-Service was conducted by DON to Licensed Nurses on 04/17/2025 regarding the importance of ensuring that all resident's discontinued medications were removed from the medication cart. d) DON and/or designee will conduct random audits of medication carts for discontinued medications. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. How the facility plans to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action must be evaluated for its effectiveness. This plan of correction is integrated into the quality assurance system: e) DON and/or designee will conduct random audits of medication carts for discontinued medications. Any issues identified during these audits will be brought forth to the five-day a week department manager morning meeting for review, validation and immediate correction. Non-compliance issues identified will be reviewed and resolved. DON and/or designee will do trending/analysis and will report to the quarterly QAPI Committee for further evaluation and/or recommendations. 05/01/2025