Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
The facility failed to follow its own policies and procedures for the management and documentation of controlled medications, specifically those stored in emergency kits (E-Kits) and in medication carts and refrigerators. Observations and interviews revealed that required shift-to-shift counts of controlled substances were not consistently documented by two staff members as required. Forms intended to record these counts and the verification of tamper-evident tag numbers on E-Kits were frequently incomplete, with missing staff initials, missing tag numbers, and days where no documentation was present at all. This pattern was observed across multiple months, with repeated instances of incomplete or missing documentation for both day and night shifts. Interviews with nursing staff confirmed that the expectation was for two staff members to count and document controlled medications at each shift change, including those in E-Kits and those prescribed to individual residents. However, staff acknowledged that there was no form or designated location to document the counts of controlled medications prescribed to individual residents, making it impossible to verify when or by whom these counts were completed. The Director of Nursing also confirmed this gap in documentation and was unaware of the frequency of missing or incomplete records for the E-Kit counts and tag verifications. Policy reviews showed that the facility's own procedures required controlled substances to be counted and documented by two staff members at every shift change, with specific forms to be used for this purpose. Despite these clear requirements, the facility did not ensure that documentation was complete or that all required counts were performed and recorded, resulting in a failure to properly account for controlled medications as mandated by facility policy.