Failure to Inventory and Document Home Medications on Admission
Penalty
Summary
The facility failed to inventory a resident’s home medications upon admission, resulting in mismanagement of those medications. The resident, who had dementia and was prescribed Norco and Klonopin, was admitted with personal belongings and home medications from an assisted living facility. The Resident Belongings/Valuables admission inventory form dated 12/11/2025 did not list any home medications, was unsigned, and noted that the resident was unable or refused to sign. Interviews with the Chief Nursing Officer and Director of Risk Management confirmed that the resident’s home medications were brought in at admission, reviewed by the admitting Nurse Practitioner, and then sent to the pharmacy, but no inventory or documentation of these medications was completed by nursing, pharmacy, or on the belongings form. The Chief Nursing Officer stated that the pharmacy evaluated the home medications to determine if any were needed temporarily and then kept them until they were returned to the resident’s daughter a few days later. The Director of Risk Management reported that the usual practice was for home medications to go to nursing and pharmacy for review and then be returned to the family, and that the facility did not keep home medications or document them on the Resident Belongings and Valuables form. The Director also confirmed there was no separate process in place to track, inventory, or document patient home medications. These practices were inconsistent with the facility’s policies, which required that medications brought in at admission be verified, counted, and documented in a log when transferred to pharmacy, and that all personal effects, including items that may affect health and safety, be recorded on the Resident Belongings and Valuables form or in the EHR. The deficient practice resulted in mismanagement of the resident’s home medications and created a high risk of lost belongings, medication omissions, and discrepancies in treatment.
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