Failure to Account for and Reconcile Controlled Medications
Penalty
Summary
The facility failed to properly account for and document the administration of controlled medications (CMs) for multiple residents, as observed during medication cart inspections and staff interviews. In one medication cart, there was a discrepancy between the Drug Control Receipt Record accountability log and the actual number of tablets remaining in the medication bubble packs for two residents. Specifically, one dose of oxycodone 5 mg was missing for a resident with a history of fracture and joint replacement, and one dose of oxycodone with acetaminophen 10-325 mg was missing for a resident with chronic pain. The responsible nurse admitted to administering the medications but failing to sign the accountability logs as required by facility policy. In another medication cart, a discrepancy was found in the count of liquid clobazam for a resident with a seizure disorder. The Liquid Controlled Drug Receipt log indicated that 48 ml should have been present, but only 30 ml remained, with no documentation of additional administrations. The nurse responsible for the reconciliation failed to identify and report this discrepancy during the shift change count, despite signing off that no discrepancies were present. The Director of Nursing confirmed that the required reconciliation process was not followed, and the discrepancy was not reported as required. Additionally, in one medication room, a medication emergency kit (eKIT) containing controlled medications was found without an accountability log for shift-by-shift reconciliation throughout the month. The registered nurse confirmed that the eKIT had not been reconciled at every shift, contrary to facility policy. The facility's policy and procedures require immediate documentation of controlled substance administration and reconciliation of all CMs at each shift change, which was not followed in these instances.