Failure to Properly Track and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly tracked and secured, as evidenced by missing licensed nurse signatures on narcotic accountability records for two of three medication carts reviewed. During audits of the East Hall and North Hall medication carts, it was observed that the narcotic accountability records had missing signatures from licensed nurses who were responsible for signing when accepting or releasing the medication carts. Staff interviews confirmed that two nurses should have signed the records at each exchange, but this procedure was not consistently followed. This deficiency was identified through direct observation and staff statements, with the potential to affect all residents receiving controlled medications.