Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to implement and follow policies and procedures to ensure accurate reconciliation of controlled substances, specifically narcotic medications, for two residents who were receiving morphine sulfate and Lorazepam. Documentation showed inconsistencies in the recorded amounts of these medications, with discrepancies between the amounts logged and the actual amounts present in the medication bottles. For one resident, the narcotic record indicated that 13 ml of morphine remained, but only 9 ml was physically present, and the log was adjusted to match the expected rather than the actual amount. Similar inconsistencies were found with Lorazepam, where the amount destroyed did not match the amount recorded as remaining, and no explanation was provided for the difference. Nursing staff, including LPNs and RNs, reported that narcotic counts had been off for some time and that they continued to document the expected amounts rather than the actual amounts present. Staff attributed discrepancies to possible spillage or evaporation and did not consistently notify nurse managers or administration when counts were incorrect. In some cases, staff relied on previous communications or assumptions rather than following the facility's policy, which required immediate notification and resolution of discrepancies before signing off on narcotic records. The consulting pharmacist was not made aware of the discrepancies until after the medications were destroyed, and routine reconciliation of narcotics was not performed by the pharmacist. The facility's own policy required that narcotics be counted at each shift change by two nurses, with immediate notification to supervisors if counts could not be reconciled. However, these procedures were not followed, and staff did not consistently document or address discrepancies as required.