Discontinued Medication Not Removed from Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that discontinued medications were promptly removed from the medication cart on the memory care unit. Specifically, a resident's Diazepam, which had been discontinued by physician order, remained in the narcotic box on the secure unit medication cart well after the discontinuation date. Record reviews showed inconsistencies and incomplete documentation on the narcotic sheet, including missing dates and signatures for administered and wasted doses. Observations revealed that the discontinued Diazepam was still present in the medication cart, and the medication administration records did not reflect proper removal or destruction of the drug. Interviews with nursing staff and the DON confirmed that discontinued medications should be removed from the cart immediately and that two nurses are required to sign off on the disposal of narcotics. However, the process was not followed, and the discontinued medication was not brought to the DON as required. Facility policies reviewed indicated that discontinued medications must be marked, removed from the cart, and stored securely until destroyed, but these procedures were not adhered to in this instance.