Failure to Maintain Accurate Shift-to-Shift Controlled Medication Counts
Penalty
Summary
The facility failed to ensure accurate shift-to-shift controlled medication counts for all residents with controlled medications stored on the Station C/Front Hall medication cart during April 2025. Facility policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, and the Narcotic and Controlled Substance Shift-To-Shift Count Sheet mandates that all resident and emergency supply controlled substances be counted at every shift change. However, review of the count sheets revealed missing or incomplete signatures for several dates in April, and the count sheet for April 19th through 30th was entirely missing. The Director of Nursing confirmed that the required documentation for these dates could not be located and that the Assistant Directors of Nursing were responsible for monitoring compliance with these counts. This deficiency potentially affected 27 residents who had controlled medications stored in the affected medication cart during the month in question.