Failure to Reconcile Controlled Medications per Policy
Penalty
Summary
Staff failed to follow facility policy and procedure for the reconciliation of controlled medications, as evidenced by missing signatures on the SHIFT CHANGE/CONTROLLED SUBSTANCE INVENTORY TRACKER documents for two medication carts. On multiple occasions, the required signatures from both off-going and on-coming nurses were absent, and in several instances, the date fields were not filled in. These omissions were observed during reviews of the narcotic reconciliation logs for the 3000-unit and 4000-unit medication carts. Interviews with staff confirmed that the narcotic inventory tracker was supposed to be signed every shift, in accordance with facility policy. The facility's policy, as provided by the Director of Nursing, requires that controlled drugs and their count sheets be reconciled and signed by both the nurse reporting off duty and the nurse reporting on duty at every shift change. Despite this, the logs reviewed showed missing signatures for several shifts, indicating that the reconciliation process was not consistently followed. No information was provided regarding the medical history or condition of any residents directly affected by this deficiency.