Failure to Properly Store and Document Controlled Substances
Penalty
Summary
The facility failed to properly store and document controlled substances on three out of four medication carts, as evidenced by unreconciled medication monitoring/control record sheets. During medication administration observations, staff were found to be signing the narcotic log after administering the medication rather than at the time of removal from the bingo card, resulting in inaccurate and untimely documentation. In one instance, a nurse admitted to forgetting to sign the log at the time of administration, and in another, a nurse did not sign the sheet due to not having a pen. Additionally, discrepancies were noted between the narcotic logs and the electronic medication administration records (EMAR), with missing dates, times, and signatures. Further observations revealed a bingo card containing controlled substances with a broken seal that had been reinforced with tape, contrary to facility protocol, which requires damaged cards to be returned to the pharmacy. The Director of Nursing confirmed that the expected procedure is for nurses to document the date, time, amount, and their initials at the time the medication is removed from the bingo card, and that any abnormalities in the bingo card should be reported to the pharmacy. The facility's policy also requires accurate and timely documentation of controlled substance administration, which was not consistently followed.