Medication Disposition Documentation and Nurse Aide Staffing Deficiencies
Summary
The facility failed to document the accounting and disposition of medications for a resident who signed out against medical advice. Upon review of the closed clinical record for this resident, there was no evidence regarding the disposition of several prescribed medications, including Atorvastatin, Diltiazem, Methimazole, Mirtazapine, and Lasix. The Director of Nursing confirmed that the facility could not provide documentation of how these medications were handled upon the resident's discharge. Additionally, the facility did not meet the required nurse aide-to-resident ratios for several shifts over a three-month period. Specifically, there were multiple instances during the day, evening, and overnight shifts where the number of nurse aides scheduled was below the minimum required based on the resident census. This was confirmed through a review of staffing records and interviews with facility leadership.
Plan Of Correction
Attempts were made to obtain documented evidence that a disposition of resident #82's medication was completed; however, it was unsuccessful. Education was provided to all registered nurses and licensed practical nurses, conducted by the director of nursing on the implementation of the disposition of medications at the time of discharge. Auditing will be completed with a review of all discharges on a weekly basis for one month and bi-weekly for three months. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, an explanation of any identified variance infractions. P 5280 P 5520 There is no evidence of any ill effect on any residents within the community due to lack of adherence to the ratio requirement for the CNA staff on the dates indicated. Current CNA ratios are presented and reviewed at the morning leadership meeting to assure compliance in accordance with the daily DOH Staffing Hours report. Identified concerns are highlighted and discussed with management for additional planning purposes. Outliers are addressed for resolution of the current daily needs. Upon identification of continued staffing needs, immediate mass texts are sent to all current staff including full-time, part-time, and PRN. In addition, needs are posted on agency sites and one-on-one conversations are held with staff to ensure staff needs are met. If continued needs exist, the group will touch base again mid-day to ensure corrective actions have been taken. Also, during the meeting, the following 3 days are reviewed to highlight any potential upcoming outlier concerns. An audit of the DOH Staffing Hour Calculator Report will be reviewed daily for two weeks and weekly for one month at the morning meeting for presentation and discussion of any variances with the established compliance requirements and actions taken to attempt to eliminate any variances. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations and explanation of any identified variance infractions.
Penalty
The facility did not document the accounting and disposition of medications for a resident upon discharge. The resident was admitted and later discharged, but by the time of the survey, there was no evidence in the clinical record regarding the medications' accounting or disposition. This was confirmed during an interview with the Nursing Home Administrator.
The facility failed to document the disposition of medications for three residents, violating its own policy. One resident ceased to breathe, another was discharged home, and a third did not return from the hospital, yet their medication records lacked necessary details such as the name of the staff disposing of the medication, the resident's name, medication name, strength, prescription number, quantity, method of disposition, and the date of disposition.
The facility failed to document the timely disposition of medications for a resident who expired, as required by their policy and state regulations. The policy lacked proper guidelines for the timely and safe identification and removal of medications for disposition. An interview with the DON confirmed the absence of documentation for the medication disposition.
A facility failed to document the disposition of medications for a resident who expired, including Atorvastatin, Insulin Glargine, and Metformin HCL, among others. This deficiency was identified through a closed clinical record review and staff interview, revealing a lack of documentation in the resident's clinical record upon discharge.
The facility did not document the accounting and disposition of medications for a resident who was admitted and then discharged after expiring. Upon review, there was no evidence in the clinical record of the resident's remaining medications or their disposition, which was confirmed by the Nursing Home Administrator.
A facility failed to document the disposition of medications for a resident upon discharge, as required by their policy. The resident was admitted and later discharged without any record of medication accounting or disposition. This deficiency was confirmed by the DON, highlighting a lapse in the facility's medication management process.
Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 109 upon discharge. Resident 109 was admitted on November 6, 2024, and discharged on January 29, 2025. However, by the time of the survey, which concluded on April 18, 2025, there was no documented evidence in the resident's clinical record regarding the accounting of remaining medications or their disposition at the time of discharge. This deficiency was confirmed during an interview with the Nursing Home Administrator on April 18, 2025, at 10:30 AM.
Plan Of Correction
P 5280 - Disposition of Medications 1. The facility cannot retroactively correct said deficiency. 2. Residents discharged within the last 14 days will be reviewed by the Director of Nursing or Designee to verify proper documentation for disposition of medications occurred. 3. Director of Nursing or Designee will re-educate licensed nurses on documentation of disposition of medications. 4. Director of Nursing or Designee will conduct audits of discharged residents daily x 2 weeks, weekly x 4 weeks and monthly x 2 months to ensure proper documentation of disposition of medications occurred. Results of these audits will be reviewed by the facility's QAPI Committee for review and recommendations.
Failure to Document Medication Disposition
Penalty
Summary
The facility failed to document the actual disposition of medications for three residents, leading to a deficiency in pharmacy services. The facility's policy on medication disposition requires detailed documentation, including the name of the staff disposing of the medication, the resident's name, medication name, strength, prescription number, quantity, method of disposition, and the date of disposition. However, this documentation was missing for three residents: one who ceased to breathe, another who was discharged to home, and a third who did not return from the hospital. Resident CR81, who had diagnoses including metabolic encephalopathy and severe protein calorie malnutrition, ceased to breathe, but the clinical record lacked documentation of medication disposition. Resident CR82, with conditions such as osteoarthritis and pancytopenia, was discharged to home without proper documentation of medication disposition. Resident CR83, who had diabetic ulcers and end-stage renal disease, was transferred to a hospital and did not return, yet the facility failed to document the disposition of their medications. These omissions were confirmed during an interview with the Regional Clinical Consultant.
Plan Of Correction
Resident CR 81, CR 82, CR 83, we were unable to complete a disposition of medications. Residents that were discharged for the last 30 days were for disposition of medications but unable to complete a disposition of medications. Residents discharged, transferred, or ceased to breathe will have a disposition of medication completed. Licensed staff were educated on the disposition of medication policy by the Director of Nursing/designee. Audit will be conducted for those residents who were discharged, transferred, or ceased to breathe weekly for 4 weeks to ensure that disposition of medication on all residents are completed by the Director of Nursing/Designee then monthly for 2 months. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.
Failure to Document Timely Medication Disposition
Penalty
Summary
The facility failed to document the timely disposition of medications for a resident, identified as Resident 167, whose clinical record was reviewed during a survey. The facility's policy on medication administration and disposition, dated September 6, 2023, outlines procedures for the timely identification and removal of medications for disposition, storage methods, control and accountability, and documentation of the actual disposition of medications. However, the policy did not provide documented evidence of proper guidelines for the timely and safe identification and removal of medications for disposition as required by 28 Pa. Code:211.9(j) Pharmacy services for discharged residents. Upon review of Resident 167's clinical record, it was found that the resident had expired on December 12, 2024, but there was no documented evidence indicating that a disposition of medications was completed upon discharge from the facility before the survey began on January 28, 2025. An interview with the Director of Nursing on January 31, 2025, confirmed the absence of documented evidence that the medication disposition for Resident 167 was completed in a timely manner.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The DON/designee will audit the last 30 days of discharged residents to ensure timely documentation of medication disposition. Licensed staff were educated on the policy of Medication administration/disposition. The DON/designee will audit discharged resident records to ensure that the medication disposition assessment is completed timely. Audits will be done weekly x 4 weeks then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is required.
Failure to Document Medication Disposition for Deceased Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 110, who expired at the facility on November 19, 2024. A closed clinical record review revealed that there was no documented evidence regarding the disposition of several medications prescribed to Resident 110. These medications included Atorvastatin, Cyanocobalamin, Insulin Glargine, Melatonin, Metoprolol Succinate, Pantoprazole Sodium, Magnesium Oxide, Metformin HCL, and Ranolazine. The deficiency was identified based on a closed clinical record review and staff interview, which confirmed the lack of documentation in the clinical record upon the resident's discharge. The facility's failure to document the disposition of these medications is a violation of the regulation requiring control and accountability of medications awaiting final disposition, as well as proper documentation of the actual disposition of medications.
Plan Of Correction
1. A disposition of medication for resident 110 cannot be retroactively produced. 2. An audit will be completed of residents who have discharged from the facility from January 6, 2025, to January 13, 2025, to ensure that a disposition of medication is completed upon discharge. 3. Education will be provided to licensed nursing staff on ensuring a disposition of medication is completed upon resident discharge. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months on residents who have discharged from the facility to ensure disposition of medication is completed. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.
Failure to Document Medication Disposition for Discharged Resident
Penalty
Summary
The facility failed to document the accounting and disposition of medications for Resident 121 upon discharge. Resident 121 was admitted to the facility on November 19, 2024, and expired and was discharged on November 21, 2024. Upon review of the clinical record during a survey ending on December 19, 2024, there was no documented evidence of the accounting of the resident's remaining medications or their disposition. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 19, 2024, at 2:00 PM.
Plan Of Correction
Step I - Unable to retroactively address for closed chart for resident 121. Step 2 - Unable to go back and fix for any discharged resident. Step 3 - Education to licensed staff on disposition of medications for discharged and expired residents. Staff educator or designee. Step 4 - Random review of discharged residents to assure disposition of medications is completed and documented at time of discharge. Weekly times 4 monthly times 2. DON or designee. Step 5 - Results to QAPI monthly times 2.
Failure to Document Medication Disposition Upon Resident Discharge
Penalty
Summary
The facility failed to adhere to its own policy regarding the disposition of medications upon a resident's discharge. Specifically, the facility's policy mandates that upon a resident's discharge or leave of absence, their medications should be immediately removed from the medication cart, and any unused medications should be disposed of. The method of disposition and the quantity of the drugs are required to be documented on the resident's chart using the Medication Disposition/Destruction Form. However, in the case of Resident 84, who was admitted on September 5, 2024, and discharged on September 24, 2024, there was no documented evidence of the accounting or disposition of any remaining medications. The deficiency was confirmed during an interview with the Director of Nursing (DON) on December 12, 2024, who acknowledged the lack of documentation regarding the disposition of Resident 84's medications. This oversight indicates a failure in the facility's process to ensure proper control and accountability of medications awaiting final disposition, as required by their policy and regulatory standards.
Plan Of Correction
Resident 84 has been discharged. To identify residents with the potential to be affected, the DON/designee will audit discharges within the last 5 days to ensure medication dispositions are complete. To prevent re-occurrence, the DON/designee will educate licensed nursing staff on the medication destruction/return process. To monitor and maintain compliance, the DON/designee will audit 5 discontinued/returned medications weekly for 4 weeks, then monthly for 2 months. All results will be brought to the QAPI committee.
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