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F0761
D

Improper Medication Disposal and Incomplete Documentation

Northridge, California Survey Completed on 05-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper disposal and documentation of medications in accordance with federal regulations and facility policy. During an observation in the medication room, a pharmaceutical waste bin was found to contain a mixture of unopened and unused medications in their original manufacturer packaging, as well as loose, intact tablets and capsules. The registered nurse present confirmed that medications were disposed of without rendering them non-retrievable, as required by policy, since no liquid was poured over them to prevent retrieval. This left the medications in a form that could be easily accessed and reused. Additionally, a review of the Medication Disposition Record/Pass Log revealed that three disposed medications—Vancomycin oral suspension, Nystatin powder, and Naloxone spray—were not documented with the required verifying signatures of two licensed nurses. Both the registered nurse and the Director of Nursing confirmed that these medications were not logged or witnessed as per policy. The facility's policy requires that all destroyed medications be entered on the disposition form with date, resident's name, medication details, and signatures of witnesses, which was not followed in these instances.

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