F0628

D

Failure to Document Medication Disposition at Discharge

Kennett Square, Pennsylvania Survey Completed on 02-20-2026

Penalty

No penalty information released

Summary

The facility failed to ensure accurate documentation of the disposition of medications upon discharge for one discharged resident. Facility policy on disposition of noncontrolled medications, revised in December 2025, required the licensed nurse to remove all of a discharged resident’s medications from the medication cart, count the remaining quantities, and document the disposition by printing the resident’s eMAR, recording the amounts of medications returned to the pharmacy on the printout, dating and initialing it, and scanning it into the EHR; alternatively, the nurse could document in an ID note the medication names, dosages, amounts remaining, and disposition. Clinical record review for Resident 51, who was discharged to independent living on December 19, 2025, showed that the nurse discharge summary stated all medications were given to the resident, but did not record or document the quantity of medications. In an interview on February 20, 2026 at 1300, the Director of Nursing confirmed that the required documentation of medication disposition was not completed for this resident, constituting noncompliance with 28 Pa. Code 211.5(d)(f) regarding clinical records.