Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain accurate records and accountability for controlled substances for one resident who was prescribed Diazepam for anxiety. During a narcotic reconciliation count on the tenth floor medication cart, it was observed that the Diazepam blister pack contained 39 half tablets, while the controlled drug record indicated that 40 half tablets should have remained. The last documented entry on the controlled drug record was inconsistent with the actual count in the medication card. The Director of Nursing confirmed that the count was incorrect. Interviews and record reviews revealed that a registered nurse had administered a dose of Diazepam to the resident, but the administration was not properly signed off on the controlled substance accountability form. Facility policy requires that all controlled substances be accounted for, with two nurses counting the medications at the beginning and end of each shift and documenting any discrepancies. The failure to accurately document and reconcile the controlled substance count resulted in a lack of accountability for the resident's medication.