Grant Memorial Hospice

“Based on document reviews and staff interviews, it was determined the facility failed to ensure proper documentation and disposal of medications in one (1) “Emergency Stash” box found in a supply closet at the agency. This failure has the potential to negatively impact all patients receiving care from the agency. A policy was reviewed titled, “Medication Disposal,” last revised 05/01/25. The policy states in part, “Purpose: To outline the process for disposal of controlled drugs in the home setting…Procedure: A. Education on Disposal of Controlled Substances 1.The nurse will instruct the patient/caregiver on the proper disposal of controlled drugs and importance of disposing of all unused medications. Patients/caregivers are provided with education on safe drug disposal and hospice medication disposal policy upon admission to hospice services. Education will include safe methods of disposal and times in which the hospice agency may assist with disposal of controlled drugs. Education regarding the destruction or disposal of controlled substances will be documented in the patient record. 2. It is recommended that patient medications that are no longer being used are disposed of safely and immediately using the following United States Food and Drug Administration (FDA) recommended method:- Remove drugs from original containers. -Conceal or remove any personal information that remains on empty medication container. -Using a disposable container with a lid or tight seal, mix drugs with an undesirable substance, such as cat litter, or use an approved manufacturer-created destruction container (such as a Deterra bag). Place sealed container and empty medication container in trash. ln the event that the patient/caregiver decline to destroy medications immediately, the hospice nurse will provide education to the patient/caregiver regarding the following Drug Enforcement Agency (DEA) safe medication destruction methods: i. Drug take-back Programs. ii. Mail-back programs. iii. Community collection receptacles for drug disposal. iv. DEA or FDA recommended physical destruction methods 3. Flush prescriptions drugs down the toilet only if the label or accompanying patient information specifically instructs doing so. The FDA advises that the following drugs may be safely flushed down the toilet instead of thrown in the trash:...B. Disposal of Patient Controlled Substances by the Hospice Agency:…3. The nurse will document in the medical record if the patient/caregiver accepts or refuses the hospice agency to assist with the disposal of the controlled substance(s). 4. Disposal of patient-controlled substances may be performed according to the following state and/or federal guidelines: 5. When hospice medications are disposed of in the presence of a hospice nurse, the disposal must be witnessed by the nurse, the patient/caregiver, and/or another employee of the hospice or facility (for facility patients). 6. The hospice nurse will document in the patient’s medical record the medication name, dosage, route, quantity, method of disposal, date and time of disposal, who disposed of the controlled substance(s), and who witnessed the disposal. 7. The hospice staff, including the hospice nurse, will not remove any medications from the patient home/facility. Any transportation of unused medications from the patient home/facility, including to the hospice agency, may result in disciplinary action, up to and including termination of employment. 8. It is strictly prohibited to store any patient medications, including medications not prescribed to a particular patient but intended for patient use, in the hospice agency. Any storage of patient-related medications in the hospice agency will be investigated and may result in disciplinary action, up to and including termination of employment…”A policy was reviewed titled, “Monitoring Medications,” last revised 11/01/17. The policy states in part, “...Procedure:...8. When controlled substances are delivered to the patient’s residence by agency staff (if permitted by state regulations) the date, patient name, medication name, medication strength, quantity indicated on the prescription container, and signatures of the hospice staff member and receiver shall be documented.”A policy was reviewed titled, “Emergency Medication Kit Usage-Hospice,” last revised 10/25/10. The policy states in part, “...Procedure: 1. Emergency medication kits left in the patient’s home must be ordered by a licensed physician. The order will contain all medications included in the kit. The nurse, physician and Pharmacist collaborate to assess each patient’s risk for specific symptoms related to the terminal illness (agitation, anxiety, pain, secretions, nausea/vomiting, fever, seizure, edema and chest pain, etc.) and the need for an emergency medication kit. The patient’s residence and caregiver situation will also be assessed and documented to ensure that placement of the emergency medication kit is safe and the drugs can be appropriately used/administered. 2. A complete list of all drugs contained within the emergency medication kit and information on each drug will be included in each kit…6. Unauthorized use of medications in the emergency medication kit will be reported to the interdisciplinary group, including the Attending Physician and/or Medical Director, and documented in the Online Event Report system.”Previous staff meeting education and notes were reviewed. On 03/13/25, in person education was received by staff 9, who signed the roster of attendance, which included the policy titled, “Medication Disposal.” An interview was conducted with staff 1 on 09/08/25 at 1:45 p.m. Regarding stashed medication, staff 1 states in part, “I sent out an email that if anyone had stash meds that they were not to be used and they were to be disposed of. There were no stashed meds in the office that I knew about. [Quality and Risk manager] and I went through this agency and looked for stash meds, and did not find any. No one confirmed there were meds on site or admitted to having any stash meds.” A telephone interview was conducted with staff 5 on 09/08/25 at 5:03 p.m. Regarding stashed medication, staff 5 states in part, “I had no idea about an extra Comfort pack kit in the office. I did not think that there was any extra kit in the building when this incident happened. I thought that [staff 2] had stockpiled them in [his/her] car. The only place that you would get extra medications is from another patient after they pass away. Medications are all patient specific, and we can’t order Clinic stock. You would have to procure them from other patients. That is the only way there could be an extra Comfort kit is from another patient. After the whole thing happened, the secretary found some medications in a closet, unsure which closet or what was found. We do not have a locked cabinet that I’m aware of. When I had first heard of the incident, I had thought [staff 2] had them in their car. It was a surprise to me that there was an extra Comfort kit in the office.” An interview was conducted with staff 7 and staff 8 on 09/09/25 at 10:06 a.m. Regarding stashed medications, staff 8 states, “Myself and [staff 13] found a box in the closet. It was a white box. [Staff 13] opened it and there were medications inside.” Staff 7 and 8 both state, “It was given to the nurse, [staff 9] to dispose of at [local] pharmacy. The box was found on the top shelf of a closet. It was on the top, sitting in the back. The closet is not locked.”A telephone interview was conducted with staff 9 on 09/09/25 at 10:57 a.m. Regarding stashed medications, staff 9 states in part, “They were medications supposedly in a stash. I destroyed a stash that someone found. I don’t know who found it and I don’t know what was in it. I destroyed it, did the kitty litter, flushing down the toilet, the whole bit. Everything is gone. I don’t remember what all was there. There were maybe a couple vials of liquid, possibly Roxanol, and a few pills but I’m not sure, I did not look. I just destroyed it like I was told. I do not know how long it has been in the office. The medications did not look expired. We did not have an emergency stash, we knew that we needed to get medications from the pharmacy.” A telephone interview was conducted with staff 10 on 09/09/25 at 11:08 a.m. Regarding the emergency medication stash, staff 10 states in part, “I did not know about the current stash of emergency meds here in the office, but I do know when I first started, we had an emergency stash. I didn’t know they continued it. When our previous executive director left, and they had cleaned out the office, they had gotten rid of the first stash.” A telephone interview was conducted with staff 11 on 09/09/25 at 11:42 a.m. Regarding emergency medications, staff 11 states in part, “I had heard about the emergency stash, but I never took from it or contributed to it. I heard about it a few weeks before it happened. After the incident was told to me, I sent a message back and told them there was an emergency stash that I heard about. I heard the other nurses talking about it. The box was kept in the clean supply closet. [Staff 9] was talking about the emergency kit and why we kept it. Obviously, [staff 2] knew about it.””

“Based on document reviews and staff interviews, it was determined the facility failed to investigate one (1) box found in an agency supply closet with “stashed medications.” This failure has the potential to negatively impact all patients receiving care from the agency. A policy was reviewed titled, “Medication Disposal,” last revised 05/01/25. The policy states in part, “...8. It is strictly prohibited to store any patient medications, including medications not prescribed to a particular patient but intended for patient use, in the hospice agency. Any storage of patient-related medications in the hospice agency will be investigated and may result in disciplinary action, up to and including termination of employment…”A policy was reviewed titled, “Emergency Medication Kit Usage-Hospice,” last revised 10/25/10. The policy states in part, “...6. Unauthorized use of medications in the emergency medication kit will be reported to the interdisciplinary group, including the Attending Physician and/or Medical Director, and documented in the Online Event Report system.”An interview was conducted with staff 1 on 09/08/25 at 1:45 p.m. Regarding stashed medication, staff 1 states in part, “I sent out an email that if anyone had stash meds that they were not to be used and they were to be disposed of. There were no stashed meds in the office that I knew about. [Quality and Risk manager] and I went through this agency and looked for stash meds, and did not find any. No one confirmed there were meds on site or admitted to having any stash meds.” A telephone interview was conducted with staff 5 on 09/08/25 at 5:03 p.m. Regarding stashed medication, staff 5 states in part, “After the whole thing happened, the secretary found some medications in a closet, unsure which closet or what was found.”An interview was conducted with staff 7 and staff 8 on 09/09/25 at 10:06 a.m. Regarding stashed medications, staff 8 states, “Myself and [staff 13] found a box in the closet. It was a white box. [Staff 13] opened it and there were medications inside.” Staff 7 and 8 both state, “It was given to the nurse, [staff 9] to dispose of at [local] pharmacy. The box was found on the top shelf of a closet. It was on the top, sitting in the back. The closet is not locked.”A telephone interview was conducted with staff 9 on 09/09/25 at 10:57 a.m. Regarding stashed medications, staff 9 states in part, “They were medications supposedly in a stash. I destroyed a stash that someone found. I don’t know who found it and I don’t know what was in it. I destroyed it, did the kitty litter, flushing down the toilet, the whole bit. Everything is gone. I don’t remember what all was there. There were maybe a couple vials of liquid, possibly Roxanol, and a few pills but I’m not sure, I did not look. I just destroyed it like I was told. I do not know how long it has been in the office. The medications did not look expired. We did not have an emergency stash, we knew that we needed to get medications from the pharmacy.” A telephone interview was conducted with staff 11 on 09/09/25 at 11:42 a.m. Regarding emergency medications, staff 11 states in part, “I had heard about the emergency stash, but I never took from it or contributed to it. I heard about it a few weeks before it happened. After the incident was told to me, I sent a message back and told them there was an emergency stash that I heard about. I heard the other nurses talking about it. The box was kept in the clean supply closet. [Staff 9] was talking about the emergency kit and why we kept it. Obviously, [staff 2] knew about it.” May it be noted, there was no investigation of the medication box found in the office, as staff 1 was not made aware of its discovery or destruction until the time of survey.”