Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to maintain an accurate and complete system for reconciling controlled substances across all five medication carts reviewed. According to the facility's policy, both the off-going and oncoming nurses are required to count and document the controlled substances at each shift change, with signatures from both parties on the Controlled Drug Count Record and Package Inventory form. However, multiple instances were identified where either the off-going or oncoming nurse, or both, did not sign the required documentation for various shifts and dates across all medication carts (a through e). In some cases, the total number of controlled medication packages reconciled was also not documented. Record reviews revealed that for numerous shifts, there was no documented evidence that the required reconciliation and documentation of controlled substances occurred. This included missing signatures and incomplete records for both the receipt and disposition of controlled drugs. The facility was unable to provide any additional documentation to demonstrate that the reconciliation process was completed as required by their policy. Interviews with nursing staff confirmed that they were aware of the requirement to reconcile and document controlled substances at each shift change, but admitted to not completing the process as required on specific occasions. The Director of Nursing also confirmed that the Controlled Drug Count Record and Package Inventory sheets were not completed with the necessary signatures at the beginning and/or end of shifts as required.