F0755

D

Improper Storage and Undocumented Disposition of Discontinued Medications

Bettendorf, Iowa Survey Completed on 02-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to properly dispose of or return discontinued, unused, or leftover medications following resident death, discharge, or changes in medication regimens. Surveyors found that for three residents, the facility could not provide documentation that medications were either destroyed or returned to the pharmacy as required by policy. The facility’s own self-reported incident indicated that an anonymous complaint to the corporate compliance office alleged theft of resident medications, and the subsequent internal investigation identified concerns with how discontinued medications were handled and stored. The facility had recently changed from one pharmacy provider to another, and medications were supplied both via an automated dispensing system and blister-pack cards, with narcotics stored under double lock in medication carts and other medications in a locked medication room.

Interviews with multiple staff revealed that discontinued medications, including narcotics, were routinely stored in the DON’s office rather than being promptly destroyed or returned. The former ADON reported that when residents were discharged or had medication changes, the former DON placed these medications in an unlocked cupboard in her office, a practice that had been ongoing for two to three years. She stated there had been at least 30 medications in that cupboard and that the former DON said they might as well keep them since they would not receive pharmacy credit. The ADON and other staff reported that the former DON gave medications from this cupboard to staff who did not have insurance and discussed helping a family member with these medications. Staff also reported that discontinued narcotics were kept in a locked drawer of the DON’s desk without any inventory or shift-to-shift count, and that only the DON had the key until the HR Manager accessed the desk during the DON’s vacation and found multiple medications, including narcotics.

The review of clinical records and pharmacy documentation for specific residents showed missing evidence of proper medication disposition. One resident who was admitted and later died at the facility had multiple medications dispensed in blister-pack form by both pharmacies, including atorvastatin, pantoprazole, warfarin, bumetanide, carvedilol, and hydroxyzine; the facility could not produce documentation of destruction or pharmacy invoices showing return of these medications after the resident’s death. Another resident who was admitted and later discharged had lidocaine 5% patches dispensed, but the facility could not provide documentation of destruction or return after discharge. A third resident, admitted and later discharged home, had several medications dispensed by the second pharmacy (bumetanide, glipizide, lisinopril, apixaban, and oxybutynin), and the facility could not provide pharmacy invoices documenting their return. Interviews with pharmacy representatives clarified that, contrary to some staff beliefs, blister-pack medications could be returned for credit under certain conditions, and facility policies required that discontinued medications be removed from active use, stored in a separate locked area, and either returned or destroyed with appropriate documentation and witnesses. These findings collectively demonstrate that the facility did not follow its own policies and applicable standards for the secure storage and disposition of discontinued and leftover medications.

Additional staff interviews further detailed the inconsistent and improper handling of discontinued medications. One LPN stated that there was a tote in the medication room where discontinued medications were placed and that, because the pharmacy often refused returns, nurses used a Drug Buster system to destroy them. However, other staff consistently described the presence of approximately 20–30 discontinued medications in the DON’s office cupboard and narcotics in the DON’s desk drawer. The HR Manager confirmed that, during the DON’s vacation, he unlocked her desk to retrieve personnel paperwork and observed at least 20 different medications in the drawer, and he reported this to the Administrator. The Administrator acknowledged that the corporate investigation confirmed medications were stored inappropriately in an unlocked cupboard in the DON’s office and that the DON had given a CNA one of these medications, which the CNA later returned during the investigation. The Administrator also stated that narcotics found in the DON’s desk included a blister-pack card and a used bottle of liquid morphine with an unknown remaining amount, and that it was not appropriate for the DON to keep narcotics in her desk. Facility policies in effect required all drugs and biologicals to be stored in locked compartments, controlled substances to be secured under double lock, discontinued medications to be removed from active use and stored in a separate locked area, and all destruction or return of medications to be documented with appropriate witnesses, which did not occur in these instances.

Pharmacy representatives provided additional context that contrasted with staff practices and beliefs. A nurse consultant from the second pharmacy stated that medications should be returned to the pharmacy when discontinued or when a resident is discharged, except for narcotics, topicals, inhalers, accessed vials, or other non-returnable items, and that returns had to occur within a specified time frame to receive credit. A representative from the first pharmacy stated that the state was a no-return state for credit, while another LTC pharmacist consultant clarified that facilities could return blister-pack medications for credit even if some doses had been used, as long as the remaining doses were sealed and intact, and that this was common practice in the state. These statements, combined with the facility’s inability to produce destruction logs or return invoices for the medications associated with the three residents, and the documented storage of discontinued medications and narcotics in the DON’s office and desk, form the basis of the deficiency related to failure to complete proper disposition of medications in accordance with policy and regulation.