Failure to Document Controlled Medication Counts and Missed Medication Administration
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed regarding the handling of controlled medications. On two separate occasions, the on-coming nurses did not sign the Narcotic Count Sheet (NCS) after counting controlled medications with the out-going nurses. Specifically, one nurse forgot to sign the NCS after the count, and another instance showed a blank NCS, making it unclear if the count was performed according to facility protocol. The Director of Nursing confirmed that both nurses should have signed the NCS immediately after the count, as per facility policy, to confirm the accuracy of the controlled medication inventory. Additionally, the facility did not administer a prescribed dose of levothyroxine to a resident with hypothyroidism, diabetes mellitus, hypertension, and morbid obesity. The medication was scheduled to be given in the morning, but documentation showed it was not administered because the medication had not yet been delivered from the pharmacy. There was no evidence that the medication was given upon receipt, nor was there documentation that the resident's physician was notified about the missed dose. The facility's policies require that controlled medications be counted and documented by both the on-coming and out-going nurses at each shift change, and that medications be administered as prescribed, with proper documentation if a dose is missed or delayed. In these instances, the required procedures were not followed, resulting in incomplete records and a missed medication dose for a resident.