Failure to Ensure Accurate Controlled Substance Reconciliation and QAPI Oversight
Penalty
Summary
The facility failed to establish and implement an effective Quality Assurance and Performance Improvement Program (QAPI) that ensured accurate reconciliation and accounting for all 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, as evidenced by missing second nurse signatures on narcotic cards and inventory count sheets. Additionally, the strength of each medication was not documented on the narcotic cards, further compromising the accuracy of controlled substance records. Staff interviews confirmed that nurses had received education on proper narcotic management, including the requirement for double signatures when receiving narcotics from the pharmacy and when discontinuing or removing narcotic cards. Despite this, the observed practice did not align with the facility's policy or the education provided, as the necessary second nurse verification was consistently absent. Audits of the narcotic books across multiple hallways showed a significant percentage of Medication Monitoring / Control Records lacking a second nurse's validation, with rates ranging from 36% to 77% depending on the hallway. Further review indicated that the facility's QAPI process did not effectively identify or address these ongoing deficiencies. Although the QAPI plan outlined systematic analysis and interdisciplinary participation, the actual implementation failed to ensure compliance with controlled substance handling procedures. Staff acknowledged that the process for counting and documenting controlled substances was not being followed as required, and that the QAPI process did not detect or resolve these issues prior to surveyor identification.