Failure to Reconcile Controlled Substances on Medication Cart
Penalty
Summary
The facility failed to properly reconcile controlled substances on the medication cart, as required by policy. Specifically, review of the controlled substance reconciliation log for the east hallway cart showed that on one occasion, only the day shift nurse signed off, with no evidence of a second staff member verifying the count. Additionally, there was no documentation or signatures indicating that a reconciliation was completed for a subsequent shift. Interviews with a Certified Medication Aide and an administrative nurse confirmed that the expectation is for two staff members to count and verify controlled substances at each shift change, in accordance with facility policy. The lack of dual verification and missing signatures on the reconciliation log demonstrated a failure to follow established procedures for controlled substance accountability.