Non-Controlled Medication Dispositions Not Witnessed by Two Nurses
Penalty
Summary
The facility failed to ensure that non-controlled medication dispositions were performed in accordance with its own policy, which requires the presence of two licensed nurses during the destruction of such medications. Over a period of nineteen months, disposition logs for non-controlled medications consistently showed that only one registered nurse signed off on the destruction, with the witness column left blank. This practice was confirmed during interviews and record reviews with the Director of Nursing (DON), who acknowledged that the process had not involved two nurses as required by the facility's policy since January 2024. The deficiency was identified during a review of medication disposition records and concurrent interviews with the DON. The most recent medication disposition involved 25 residents' non-controlled medications, all documented with only one nurse's signature. The DON confirmed that this had been the standard practice for at least nineteen months, and that the facility's written policy, which mandates two licensed nurses for non-controlled medication destruction, had not been followed during this period.