Failure to Ensure Accurate Reconciliation and Verification of Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate system for reconciliation and accounting of controlled medications across four out of six sampled medication carts. Observations revealed that narcotics were added to medication carts for multiple residents without the required verification by a second nurse. In several instances, narcotic cards lacked documentation of medication strength, and the necessary second nurse signature was missing on both the narcotic cards and the Shift Change Controlled Substance Inventory Count Sheets. These deficiencies were observed during medication cart checks on multiple hallways, with staff confirming that they had received education on the correct procedures, which included double signatures for receiving and discontinuing narcotics. Further review of narcotic books across all hallways showed a significant proportion of Medication Monitoring / Control Records were not initialed or validated by a second nurse, with non-compliance rates ranging from 36% to 77% depending on the hallway. Staff interviews confirmed that the process for counting and documenting controlled substances was not consistently followed, and that the facility's policy did not explicitly require two nurse initials on individual narcotic Medication Monitoring / Control Records. Despite education and audits, the required verification steps were not reliably performed, leading to incomplete documentation and lack of proper chain of custody for controlled substances. The facility's policies outlined procedures for the acceptance, counting, and disposal of controlled drugs, including the requirement for two nurses to open and reconcile pharmacy deliveries and to count controlled substances at shift change. However, observations and record reviews demonstrated that these procedures were not consistently implemented in practice. The lack of adherence to established protocols resulted in discrepancies in the documentation and verification of controlled medications, as evidenced by missing second nurse signatures and incomplete records.