Failure to Document Disposition of Controlled Medication After Resident Discharge
Penalty
Summary
The facility failed to document the disposition of medication for a discharged resident, specifically regarding 30 Morphine Sulfate Oral Tablets that were not administered. Facility policy requires that all medications not taken by the resident upon discharge must be disposed of according to federal, state, and local regulations, with proper documentation of the process. In this case, the resident was admitted to a hospital for observation due to chronic mid-line low back pain, and there was no further documentation regarding the resident's discharge or the handling of the remaining medication. A review of the closed records did not reveal any documentation indicating what happened to the unused Morphine Sulfate tablets. The DON confirmed during an interview that there was no medication disposition sheet for this resident. This lack of documentation is a violation of both facility policy and regulatory requirements for pharmaceutical services and recordkeeping.