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Based on observation of medication administration, record review, and staff interview the facility failed to ensure that medication was handled and dispensed according to the facility policy for one patient (Patient 17). The facility policy failed to include where destroyed medications were discarded. This had the potential to affect all patients. The census was 1 swing bed resident.

Findings are:

A. Observation of Patient 17's Medication Administration on 7/9/19 at 4:45 PM revealed:
-RN (Registered Nurse) D washed the nurse's hands with soap and water and then went to the computer at the Nurses' Statopm to review the patient's physician's order.
-The patient had an order for Coumadin (Warfarin -a blood thinner to prevent blood clots) 2.5 mg (milligrams).
-RN D dispensed a Coumadin 5 mg tablet from the Med Dispense system. The nurse put the Coumadin into bare hands and split the tablet into two pieces and placed the pieces into 2 soufflé cups.
- RN D checked the order again and entered the patient's room without washing or sanitizing hands. The RN asked the patient's name and birthday and gave the patient the medication. The RN left the room without washing or sanitizing hands.
-RN D returned to the computer at the nurses station and documented that the medication was given and one half of the medication
was discarded in the open trash can at the Nurses' Station.

B. Interview on 7/9/19 at 4:45 PM with RN D revealed that the Med Dispense did not contain Coumadin 2.5 mg tablets. RN D stated that the Coumadin could be broke into two pieces since it was scored. Normally most medications would be broke with the assistance of the pill splitter. The extra half of the medication would be discarded into the trash can. If it was a controlled substance, the nurse would place it in the sharp container.

C. Interview with the Clinical Manager on 7/10/19 at 10:11 AM revealed that RN D should have worn gloves when handling the medications. The pill splitter was provided to ensure that the medication was more accurately cut in half even if the medication was scored. The RN should have washed or sanitized hands when entering and exiting the patients room. On review of the facility policy, the RN reported that the policy did not include how the RN should discard the medication.