Failure to Maintain Accurate Controlled Medication Records
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain accurate records of controlled medications for one of two medication carts, specifically Medication Cart 1. Review of the Controlled Medication Shift Count (CMSC) form revealed two missing signatures for the night shift, indicating that the required verification and documentation by two licensed nurses at shift change did not occur on those occasions. This was confirmed by a nurse and the DON, who both acknowledged that the facility's policy requires two licensed nurses to conduct and sign off on narcotic counts at each shift change, and that this procedure was not followed as documented.