Failure to Properly Dispose of Discontinued and Unused Medications
Summary
Surveyors identified multiple failures in the facility's handling of discontinued and unused medications. During observations, medications belonging to two discharged residents were found left inside a medication room refrigerator, despite both residents having been discharged weeks prior. Additionally, discontinued medications for two other residents were found disposed of in their original containers inside resealable plastic bags within a disposal bin, rather than being properly destroyed according to facility policy. Further, various discontinued medications, including birth control pills, were left intact and undisposed in a disposal bin, and a discontinued medication for another resident was found stored among active medications in a medication cart. Interviews with licensed nurses confirmed that the medications found belonged to residents who were no longer in the facility or whose medication orders had been discontinued. Record reviews corroborated the discharge dates and medication discontinuation orders for the affected residents. The facility's policy requires that discontinued and unused medications be destroyed in compliance with federal and state regulations, and that such medications be removed from storage areas and secured until destruction. Despite these requirements, the facility failed to properly identify, segregate, and dispose of discontinued and unused medications. The observed practices included leaving medications accessible in medication rooms and carts, and placing them in disposal bins without proper destruction. These actions were not in accordance with the facility's own policies or regulatory requirements for pharmaceutical service, labeling, and storage.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 Inservices with licensed staff regarding the facility policy and procedure titled Discarding and Destroying Medications. Licensed staff will follow the facility protocol for proper disposal and destruction of unused and discontinued medications. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medications 3 times a week for 3 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused medications 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor for proper disposal and destruction of unused and discontinued medication randomly for 1 month. System Effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three months.
Penalty
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