Failure to Document Narcotic Accountability for 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 medication carts. During audits of the 300-Wing and A-Wing medication carts, it was observed that the narcotic accountability records spanning several weeks were missing six and five required nurse signatures, respectively. Both the Director of Nursing (DON) and a registered nurse confirmed that two nurses should have signed the narcotic accountability record when accepting or releasing the medication cart, but this was not consistently done. This lapse in documentation created the potential for undetected misuse or diversion of controlled medications for all residents receiving such medications.