Failure to Reconcile and Co-Sign Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to maintain a system for periodic reconciliation and accounting of all controlled medications on the East B medication cart. Specifically, nurses were required to count all schedule two, three, and four medications at each shift change and co-sign the medication ledgers to confirm the accuracy of the counts. However, review of the schedule three and four medication ledger revealed that nurses rarely signed to validate the counts, with only one of 62 shift changes in January, none in February, and one of 62 in March having the required signatures. Interviews with staff confirmed that the expected process of dual verification and signing was not consistently followed. Staff interviews indicated inconsistency in practice, with some nurses signing the ledger and others not, and some believing that a single signature sufficed for both schedule two and schedule three/four ledgers. The Resident Care Manager confirmed that the required process of both oncoming and offgoing nurses signing the ledger for schedule three and four medications was not being followed for the East B cart. No specific residents were identified as being directly affected in the report.