Failure to Document Receipt and Shift Counts of Controlled Substances
Penalty
Summary
The facility failed to establish and maintain a system for accurately documenting the receipt and disposition of all controlled drugs, as required by policy and regulation. Specifically, there was no documentation of the receipt of Oxycodone, a Schedule II narcotic pain medication, for a resident with hemiplegia, hemiparesis, pain, and anxiety disorder. The individual controlled substance administration record for this resident did not include the signature of the person receiving the drug, the date received, or the amount received, as required by the facility's policy. Additionally, the facility did not consistently document the required signatures of both the off-going and oncoming nurses on the narcotic and controlled substance shift count sheets for both the first and second-floor nursing units. Multiple instances were identified where signatures were missing for either or both nurses during various shifts across different dates. This lack of documentation occurred despite the facility's policy requiring both nurses to count and sign for controlled substances at each shift change. Interviews with nursing staff and the Director of Nursing confirmed that while narcotics were counted, the required documentation was not always completed. Staff acknowledged awareness of the process and responsibility for counting and signing for controlled substances, but admitted to not consistently signing the records. The Director of Nursing also confirmed the expectation that narcotics should be counted and documented by two nurses at the time of receipt and at each shift change.