Failure to Reconcile Controlled Medications in Emergency Kits
Penalty
Summary
The facility failed to reconcile controlled medications (CMs) in emergency medication kits (eKITs) at every shift in two separate locations: Medication Room Station 1 and Medication Cart Station 2B. During observations and interviews, it was found that the eKIT labeled 109 in Medication Room Station 1 and the eKIT labeled 318 in Medication Cart Station 2B, both containing CMs, did not have accountability logs documenting reconciliation of CM inventory for the month of May 2025. Registered and vocational nursing staff confirmed that these eKITs were not reconciled at every shift, 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 policy and procedure on controlled medication storage indicated that all CMs, including those in emergency supplies, must be physically inventoried by two licensed nurses and documented at each shift change. Despite this policy, the required reconciliation and documentation were not performed for the identified eKITs in the specified medication room and cart, resulting in a lack of compliance with federal and state regulations regarding the handling of controlled substances.