Failure to Consistently Reconcile and Document Controlled Substances at Shift Change
Penalty
Summary
The facility failed to ensure staff followed established policy and procedure for the reconciliation of controlled substances on two of six medication carts reviewed. During observations of medication storage, multiple instances were identified where the required signatures of on-coming and off-going nurses were missing from the Controlled Substance Shift Change Count Records for the South and Southwest medication carts. These missing signatures occurred across several dates in February, April, and May, indicating that the process for jointly counting and signing for controlled substances at shift changes was not consistently followed. Interviews with staff confirmed that the expectation was for two licensed nurses to count narcotics together and sign the log at each shift change, as outlined in facility policy. The reviewed policy documents also specified that two licensed nurses must account for all controlled substances and access keys at the end of each shift. Despite these requirements, the observed documentation showed repeated failures to obtain the necessary signatures, demonstrating noncompliance with the facility's controlled substance accountability procedures.