Medication Management Lapse During Shift Change
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications and proper handling of medication cart keys during a shift change. On one occasion, an Agency LPN left the facility without conducting a required physical inventory of medications with the incoming nurse, as per the facility's policy. The LPN left the medication cart keys in her car, which was taken by her son, resulting in the keys being unavailable for the incoming nurse. This incident occurred on the 3-West low hall medication cart, and the failure to follow protocol was confirmed by the Director of Nursing. During the shift change, the incoming LPN was unable to access the medication cart due to the absence of keys and did not perform the necessary medication count with the outgoing LPN. The RN Supervisor and the incoming LPN later conducted a count and discovered discrepancies, with two narcotic medications missing. The facility's policy requires that any discrepancies be addressed immediately with a supervisor, but this procedure was not followed initially. The incident highlights a lapse in adherence to established protocols for medication management and key handling during shift changes.
Plan Of Correction
Immediate education regarding Policy M-N-19 Medications - Narcotics Controlled Substances, DEA's, was provided to every licensed staff member working the 3-11, 11-7 shift on 2-4-2025 and daylight on 2-5-2025. DON/ADON/Designee will continue education regarding Policy M-N-19 Medications - Narcotics Controlled Substances, DEA's to all licensed nursing staff daily and Policy will be included with orientation packet for all agency licensed nursing staff. Audits of the controlled inventory sheets will be done at change of shift daily x 7 days, 3x per week for 2 weeks, weekly x4. All results will be reported to the QAPI Committee for review.