Every finding on record at Quad County Hospice

Based on document review and staff interview, the Hospice failed to A.) have a policy and procedure for the management and disposal of controlled drugs in the patients home and B.) failed to ensure drugs were tracked and disposed of in accordance with its policy. --- A. Findings include: 1. The Hospice policy titled "Drug Disposal" (revised 1/2022) was reviewed on 9/15/2023 at approximately 10:00 AM. The policy required, "At the time of death, discontinuance, or expiration of a medication: Medications are disposed of using the ";Drug Buster Disposal System ...". 2. The clinical record of Pt #6 was reviewed on 9/13/2023. Pt #6 was admitted to Hospice services on 8/2/2023 with a diagnosis of Malignant Neoplasm of Right Pelvis, Pt #6 expired on 9/1/2023. The ";Skilled Nursing Note" dated 9/1/2023, lacked documentation in the ";Controlled Substance Disposal" record the number of Dilaudid 2 mg oral tablets disposed of, and the number of Lorazepam 1 mg tablets disposed. The ";Controlled Substance Disposal" record also lacked the documentation of the disposal of the morphine 20mg/ml oral concentrate. 3. An interview was conducted on 9/15/2023 at 10:30AM with the Director of Hospice (E #1). E #1 reviewed Pt #6s chart and agreed the number of narcotic tablets disposed of should have been listed as well as destruction of the morphine. B. Finding include: 1. The clinical record of Pt #6 was reviewed on 9/13/2023. Pt #6 was admitted to Hospice services on 8/2/2023 with a diagnosis of Malignant Neoplasm of Right Pelvis. Pt #6s clinical record lacked documentation the written policy and procedure for management and disposal of controlled drugs was provided to the patient. 2. On 9/13/2023 the ";Hospice Admission Booklet" was reviewed. On page 33 the ";Hospice Admission Booklet" indicated the RN will initiate the hospice policy and procedure Management and Disposal of Controlled Drugs...The nurse will document in the patients clinical record that the written policy and procedure for management and disposal of controlled drugs was provided.. 3. An interview was conducted on 9/15/2023 at 10:40AM, with the Director of Hospice (E #1). E #1 was unable to provide the policy titled ";Management and Disposal of Controlled Drugs".