Incomplete Documentation of Controlled Medication Disposition
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for two residents when controlled medication entries for both individuals did not include received by dates in the controlled drug disposition log. Specifically, three controlled medications for one resident and four for another were listed for disposition without the required documentation of when the medications were received by the DON from the floor nurse. The DON confirmed during interviews that the received by date was not documented for these entries, which was contrary to facility policy and procedure. Interviews with both the DON and the facility pharmacist revealed that the expected process was for the floor nurse to bring controlled medications for waste to the DON, who would then document all required information, including the received by date, in the disposition log. Both the DON and the pharmacist emphasized the importance of this documentation for ensuring timely and accurate disposal of controlled medications. The absence of received by dates meant that the facility could not verify when the medications were received or ensure they were disposed of within the required three-month timeframe. A review of facility policies confirmed that all controlled substances must be properly documented upon receipt and during disposal, including the date received, to comply with federal, state, and local regulations. The DON acknowledged that the policy was not followed in these instances, resulting in incomplete records for the controlled medications of both residents.