Failure to Document and Safeguard Controlled Medications
Penalty
Summary
The facility failed to ensure proper accounting and safeguarding of controlled medications by not maintaining complete and accurate documentation on the Narcotic Card/Bottle Count Sheets for multiple medication carts over several months. Specifically, for Medication Cart C in February and March, and Medication Cart D in February and April, there were numerous instances where required staff signatures were missing for both incoming and outgoing shifts across all three daily shifts. Additionally, there were several occasions where the total number of narcotic cards and bottles was not documented by either on-duty or off-duty staff as required. These deficiencies were confirmed during interviews and concurrent document reviews with licensed vocational nurses, who acknowledged that it was the responsibility of licensed nurses to count and sign for the narcotic cards and bottles at the start of their shifts. The lack of proper documentation and signatures on the count sheets had the potential for controlled substance diversion, as the facility did not ensure that the required procedures for tracking and safeguarding controlled medications were consistently followed.