Failure to Maintain Accurate Controlled Substance Shift Counts
Penalty
Summary
The facility failed to maintain an adequate system for recording the receipt and disposition of all controlled drugs, resulting in insufficient detail to enable accurate reconciliation. During a review of three medication carts (Cart A, Cart B & C, and the Nurse Treatment cart), it was observed that the required signatures from two authorized medication administrators were missing from the Shift Count pages on multiple dates. The facility's policy requires that incoming and outgoing nurses count all Schedule 2 controlled substances and other medications with a risk of abuse or diversion at each shift change and document the results on a Controlled Substance Count Verification/Shift Count Sheet. However, on numerous occasions, the required documentation was not completed as indicated by the absence of signatures, despite the facility's practice of counting controlled substances approximately three times a day at shift changes. The Director of Nursing Services confirmed the findings, acknowledging that a significant number of required signatures were missing from the narcotic books. The deficiency was identified through record review, observation, and staff interview, and it was corroborated by the facility's own policy dated 8/1/24, which outlines the procedures for inventory control of controlled substances. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.