Failure to Document Medication Destruction for Hospitalized Resident
Penalty
Summary
The facility failed to ensure proper documentation and completion of a medication destruction form for a resident who was hospitalized. The resident, who had diagnoses including paraplegia, psychosis, hypertension, and spinal fusion, was prescribed Augmentin for a wound infection. The medication was started and administered for several days, but after the resident was admitted to the hospital, there were six remaining tablets that were not accounted for. The resident's record did not contain documentation of a Drug Disposition form for the remaining medication. Interviews with nursing staff and review of the medication cart confirmed that the required drug destruction documentation was missing, and the remaining medication was not found in the cart. The facility's policy required discontinued medications to be destroyed or returned to the pharmacy and documented accordingly, but no such documentation was present for this resident's unused antibiotics.