Failure to Accurately Reconcile Controlled Substances Across Medication Carts
Penalty
Summary
The facility failed to maintain an accurate and complete system for reconciling controlled substances across all six medication carts reviewed. Documentation revealed that on numerous occasions, the required signatures from both off-going and oncoming nurses were missing from the Narcotic Nurse Sign on/off logs for each medication cart. These omissions occurred on multiple shifts throughout the month, with some carts lacking signatures for both nurses on consecutive days and shifts. In several instances, there was no documented evidence of the receipt and disposition of all controlled drugs for the specified dates and times. Interviews with nursing staff confirmed that the reconciliation process was not consistently followed as required. One LPN acknowledged that the sign on/off log for a medication cart was not completed as it should have been, and that both nurses were supposed to reconcile the controlled substances together at shift change and sign the log. Another LPN admitted to signing the log at the beginning of her shift, rather than at the end, which was not the correct procedure. Additional staff interviews indicated that the approved reconciliation logs were not used for certain medication carts during the relevant shifts. The Director of Nursing confirmed that the Narcotic Nurse Sign on/off logs were not completed with the necessary signatures at the beginning and/or end of shifts as required. The DON also acknowledged that the approved logs were not used for some medication carts. There was no documentation provided by the facility to dispute these findings or to demonstrate that the required reconciliation of controlled substances had occurred during the identified shifts.