Failure to Document and Account for Resident's Medication Brought in by Family
Penalty
Summary
The facility failed to ensure a system was in place for the documentation and disposition of a resident's medication, resulting in the resident's weight loss medication being unaccounted for. The resident, who had a complex medical history including morbid obesity, depression, lymphedema, hypothyroidism, and a recent tracheostomy, was readmitted to the facility after a hospital stay. The resident reported that her weight loss medication, which was brought in by her family and required refrigeration, was missing upon her return. She stated that she had two doses left, but staff could not locate them, and she subsequently missed two doses. Multiple staff interviews revealed confusion regarding the handling and documentation of medications brought in by family members, with some staff stating that medications are typically sent back to the pharmacy or discarded when a resident is hospitalized, but no clear documentation or process was followed in this case. Nursing staff provided inconsistent accounts regarding the disposition of the medication. Some staff indicated that medications not classified as controlled substances, such as the resident's injectable weight loss medication, were discarded without documentation, while others were unaware of the medication's origin or storage requirements. One LPN admitted to discarding the medication after a period of time, along with other medications, but did not document this action. There was also a lack of clarity about whether the medication should have been returned to the family, kept in a secure location, or sent back to the pharmacy, and no records were maintained to track the medication's disposition. The Director of Nursing and the Administrator both acknowledged the absence of a policy regarding the handling and documentation of medications brought in by family members. The Administrator confirmed that there was no existing policy on medication disposition, and staff were not aware that the medication in question had been provided by the resident's family. The lack of a clear process and documentation led to the medication being unaccounted for and the resident missing prescribed doses.