Failure to Reconcile Controlled Medications in Emergency Kits
Penalty
Summary
The facility failed to reconcile eight medication emergency kits (eKITs) containing controlled medications (CMs) in one medication room for the month of April 2025. During an observation, four eKITs stored in a cabinet and four eKITs stored in a refrigerator, all containing CMs, were found without accountability logs documenting reconciliation of CM inventory at every shift change. Both a registered nurse and the Director of Nursing confirmed that these eKITs were not reconciled at each shift change as required, and acknowledged the importance of this process for accountability and prevention of CM diversion or accidental exposure. A review of the facility's policies and procedures indicated that all controlled substances, including those in emergency kits and under refrigeration, must be reconciled by two licensed nurses and documented at each shift change. The lack of reconciliation and documentation for these eight eKITs did not comply with the facility's own policies or with federal and state regulations regarding the handling, storage, and recordkeeping of controlled medications.