Failure to Accurately Account for and Document Controlled Substances
Penalty
Summary
The facility failed to ensure accurate accountability and documentation of controlled substance medications for its residents. For two residents who had physician orders for hydrocodone/APAP, the Controlled Drug Record (CDR) indicated that doses were removed from the medication cart, but these administrations were not documented on the Medication Administration Record (MAR). This discrepancy was confirmed during interviews with the Director of Nursing (DON), who stated that nurses were expected to document every pill removed and administered, as outlined in the facility's policies. Additionally, the facility did not consistently obtain signatures from both the off-going and on-coming nurses on the controlled drug shift-to-shift count records for two medication carts. Review of these records revealed multiple missing signatures for various shifts, which was acknowledged by nursing staff and the DON. Facility policy required both nurses to count and sign for controlled medications at each shift change to ensure accountability. Furthermore, the removal of a narcotic medication from the emergency kit (e-kit) was not fully documented. During an inspection, a narcotic e-kit was found with a log indicating a tramadol tablet had been removed, but the date and time of removal were not recorded. Both the Infection Preventionist/Interim Staff Development and the DON confirmed that staff were expected to complete the log in full, in accordance with facility policy.
Plan Of Correction
Plan to Monitor Performance: 1. The DSD will monitor the controlled drug records at each cart to ensure they are signed by the outgoing and incoming nurses properly. Checks will be done daily for 1 month and then weekly for the next 4 months to ensure continued compliance. 2. The DON will audit emergency kit logs weekly for 4 weeks, then monthly for 3 months to ensure complete documentation. 3. Random controlled substance reconciliation audits will be conducted by the Consultant Pharmacist during monthly visits. The Director of Nursing will report audit findings to the Quality Assurance and Performance Improvement (QAPI) committee quarterly for review and recommendations. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained. All corrective action to be completed by 5/26/25.