Failure to Accurately Reconcile and Secure Controlled Medications
Penalty
Summary
Surveyors observed that the facility failed to accurately maintain and reconcile controlled medication logs for two residents receiving narcotics. During medication cart inspections, discrepancies were found between the number of tablets or capsules present in medication punch cards and the amounts recorded on the Controlled Substances Proof of Use sheets. For one resident, the Tramadol punch card was empty while the log indicated one tablet should remain, and the Pregabalin punch card contained 30 capsules while the log showed 31. Additionally, several punch slots were torn with loose, unsecured capsules. For another resident, the Tramadol punch card had one tablet, but the log showed two remaining. The Assistant Director of Nursing was unable to explain the discrepancies, and a Registered Nurse admitted to not logging the administration of scheduled controlled medications for these residents. The facility's policy required that controlled substances be reconciled upon receipt, administration, disposition, and at the end of each shift, and that proper storage and logging be maintained to prevent discrepancies. However, the observed failures to log medication removal and to secure medication cards led to inaccurate records and improper handling of controlled substances. The Director of Nursing confirmed that nurses were expected to ensure accurate storage, disposition, and logging of controlled medications, but these expectations were not met in the cases reviewed.