Failure to Ensure Controlled Drug Audit Records Were Consistently Signed
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that the Controlled Drugs Audit Record for the 100/300/unit nurses' medication cart was consistently signed before and after each shift over a period of several months. Record reviews revealed a total of 28 missing nurse signatures across the months of October 2024 through April 2025. Specific dates and shifts were identified where either the on-coming or off-going nurse did not sign the audit record, as required by facility policy. Interviews with nursing staff and leadership confirmed that the expected process was for two licensed nurses, or a nurse and a CMA as allowed by state regulations, to count and sign for controlled medications at each shift change. LVN A acknowledged that the missing signatures could be due to forgetting or being interrupted during the count. The DON and Administrator both stated that their expectation was for all required signatures to be present to verify that the medication count was completed and to prevent potential drug diversion or missing medications. The facility's Controlled Medications - Administration policy required a physical inventory of all controlled medications at each shift change, with documentation on an audit record. Despite this policy, the audit records for the medication cart showed repeated lapses in obtaining the necessary signatures, indicating that the process was not consistently followed or monitored.