Failure to Accurately Account for Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure accurate accounting of controlled medications across five medication carts. The deficiency was identified through a review of the facility's policy, controlled medication shift reconciliation records, and staff interviews. The facility's policy, dated 8/28/24, requires that incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at each shift change or at least once daily, documenting the results on a 'Controlled Substance Count Verification/Shift Count Sheet.' However, this procedure was not consistently followed. During the review of the 'Controlled Medication Shift Reconciliation' logs for various medication carts, it was found that on several occasions, either the oncoming or outgoing nurse failed to sign the sheet during shift changes to verify the counts of controlled drugs. Specific dates were noted for each cart where signatures were missing, indicating a lack of compliance with the facility's policy. Interviews with LPNs confirmed these observations, acknowledging that signatures were indeed missing where they should have been present. The Nursing Home Administrator confirmed the facility's failure to implement the necessary procedures to promote accurate accounting of controlled medications on all five medication carts reviewed. This deficiency was noted as a violation of both the facility's policy and the regulatory requirements for pharmacy services, as outlined in 28 Pa. Code 211.12 (d)(3)(5) and 28 Pa. Code 211.19(a)(1)(k).
Plan Of Correction
There were no residents affected by this deficient practice. All residents have the potential to be affected. To prevent this from recurring, education will be provided to licensed nurses regarding the importance of accurate accounting of controlled medications with the use of the "inventory or controlled substances policy." The Director of Nursing (DON)/designee will provide education to licensed nurses regarding the importance of accurate accounting of controlled medications with the use of the "inventory or controlled substances policy." For ongoing compliance, the DON/designee will conduct audits of accurate accounting of controlled medication sheets to verify proper signatures 3 times per week for 4 weeks, then weekly for 2 weeks to ensure compliance. Any noted discrepancies will be addressed as appropriate, and results of auditing will be reviewed at the facility Quality Assurance Meeting.