Failure to Immediately Dispose of Dropped Controlled Medication
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring the immediate and secure disposal of a controlled medication, Lorazepam, prescribed for a resident with severe cognitive impairment and multiple medical conditions, including encephalopathy, respiratory failure, chronic kidney disease, and cerebrovascular disease. The resident was receiving hospice care and had a physician's order for Lorazepam to be administered via a gastrostomy tube as needed for anxiety. During medication preparation, an RN dropped a Lorazepam tablet on the floor but did not immediately pick it up or dispose of it. Instead, the RN prepared a new dose for administration and left the dropped tablet unattended on the floor, out of her sight due to a privacy curtain. The RN completed the medication administration and other tasks before returning to the dropped tablet, at which point she called the ADON to witness its disposal. The tablet was then crushed and disposed of in a sharps container, and the narcotic sheet was co-signed. Interviews with the RN, ADON, DON, and Administrator confirmed that the expectation was for controlled substances to be disposed of immediately and not left unattended, as leaving the medication on the floor could result in unauthorized access or ingestion. The facility's policy required the immediate disposal of contaminated controlled substances, but this procedure was not followed in this instance.