Failure to Document Medication Disposition for a Resident
Penalty
Summary
The facility failed to maintain proper documentation regarding the disposition of medications for a resident with multiple complex medical conditions, including hypertensive heart disease with heart failure, atrial fibrillation, a prosthetic heart valve, a defibrillator, and chronic liver disease. Specifically, after a medication error was identified in which the resident received an incorrect dosage of Torsemide, the Director of Nursing (DON) destroyed four prescription cards of the medication but did not document the prescription numbers, quantity, or date of destruction as required. The medication destruction log did not include the destroyed Torsemide, and the resident's medical record lacked evidence of the medication's proper disposition. Interviews with facility staff and review of the facility's Medication Destruction Policy confirmed that all medications delivered to the facility are considered the property of the resident and that a log must be completed for any medication disposed of, including specific details such as resident name, prescription number, quantity, date, and staff signature. The consulting pharmacist and registered nurse both acknowledged that the required documentation was missing for the destroyed Torsemide, and the DON admitted to not recording the necessary information at the time of destruction.