Failure to Accurately Monitor and Reconcile Narcotic Medications in Emergency Kits
Penalty
Summary
The facility failed to maintain an accurate and adequate system for monitoring and reconciling narcotic medications stored in emergency kits (e-kits). During a tour of the medication room, it was observed that the lock-out tag numbers on two e-kits containing controlled substances, including hydrocodone-acetaminophen, morphine sulfate, alprazolam, APAP-Codeine #3, clonazepam, lorazepam, zolpidem, and tramadol, did not match the numbers documented on the Controlled Medication Shift Count sheet. A review of the shift count sheet revealed that staff had signed off on the count and reconciliation of the e-kits only three times over a one-month period, rather than at every shift change as required by facility policy. Interviews with nursing staff confirmed that the lock-out tags on the e-kits were not being checked and documented by oncoming and off-going nurses at shift change. The administrative nurse stated that it was the facility's expectation for nurses to verify the lock-out tag numbers and sign the reconciliation form at the beginning and end of each shift, in accordance with the facility's Controlled Medication Reconciliation policy. The failure to follow these procedures resulted in a lack of proper monitoring and reconciliation of controlled medications in the facility's emergency kits.