Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a complete and accurate system for recording the receipt and disposition of all controlled medications. During a review of the bi-monthly narcotic drug audit, it was found that while audits were being conducted to check for locked medication carts, proof of use sheets, correct narcotic counts, signed shift change count sheets, correct labeling, and removal of expired medications, there was a lack of comprehensive reconciliation between the yellow and white Controlled Substance Disposition Records (CSDR). The oldest yellow CSDR sheet had not been reconciled with the corresponding white CSDR, nor had the medications been documented as destroyed, and audit sheets were missing from the record book. An interview with the ADNS revealed that she was responsible for the controlled drug audits, which were performed twice a month. However, she stated that she did not audit the yellow CSDR sheets until she received the white CSDR sheets from the nursing units, resulting in incomplete and delayed reconciliation. The facility's own policy required special record keeping for all controlled drugs, but the current practice did not ensure adequate medication reconciliation, leaving the system vulnerable to medication diversion.