Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. This deficiency was identified during observations and interviews with staff, as well as a review of facility policies. The facility's policy on 'Controlled Substances' requires that controlled substance inventory be monitored and reconciled to identify loss or potential diversion, with nursing staff counting controlled medication inventory at the end of each shift. However, it was found that there was no documentation in the narcotic log books for several periods across three medication carts on the first floor, indicating that shift-to-shift counts were not completed as required. During observations on January 21, 2025, it was noted that the narcotic log books for the first floor front, back, and middle medication carts lacked documentation of shift-to-shift counts for various dates spanning from October 2024 to January 2025. Interviews with the licensed nurses responsible for these carts confirmed the absence of required documentation. In one instance, a nurse attempted to sign the log book without a corresponding signature from the previous shift, further indicating a lapse in the reconciliation process. These findings demonstrate a failure to adhere to the facility's policy and regulatory requirements for maintaining accurate drug records.
Plan Of Correction
1. Unable to retroactively correct. No adverse effects were noted. 2. An initial audit was conducted to validate shift to shift counts in narcotic log books are completed. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate the licensed nursing staff on proper documentation of shift to shift counts in the narcotic log books. 4. DON/Designee will conduct random audits of narcotic log books to ensure documentation of shift to shift counts are completed. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.