Inaccurate Narcotic Drug Counts and Recordkeeping
Penalty
Summary
The facility failed to maintain accurate drug records and account for all controlled substances on two nursing units. During observations, discrepancies were found between the narcotic count logs and the actual number of medications present in the drug packs. On the East unit, the narcotic count log for hydrocodone-acetaminophen 5-325 mg tablets indicated 23 available, but only 22 were present, and another log indicated 30 available with only 29 present. The RN responsible stated she may have forgotten to sign out the medications after administration, as she typically signs the narcotic log as she gives them. On another unit, similar discrepancies were observed. The count log for clonazepam 0.5 mg tablets showed 17 available, but only 16 were present, and the log for Ativan 1 mg tablets showed 8 available, but only 7 were present. The QMA responsible indicated she was passing medications on two halls and was behind, but normally signs the medication out as she gives it. The facility's policy requires each dose to be recorded at the time of administration and the drug supply to be confirmed before and after assembling the required dose, including documentation of date, time, dosage, signature, and quantity remaining.