Failure to Accurately Reconcile Controlled Substance Medication
Penalty
Summary
The facility failed to accurately reconcile a resident's controlled substance medication, specifically Lacosamide 150mg, as required. Medical record review showed a physician's order for the resident to receive Lacosamide 150mg twice daily. On review of the medication cart and the resident's blister pack, there were 8 tablets present, while the controlled substance count sheet indicated there should have been 7 tablets remaining after the last documented administration. The count sheet showed that staff had signed off that the medication was administered and the count was correct, but this did not match the actual number of tablets in the blister pack. Further investigation revealed that the shift count sheet for the controlled substances was signed off by one staff member without completing the count with another nurse, as required during shift changes. Staff interview confirmed that the count was incorrect and that the medication had not been administered as documented. The staff member also acknowledged that the shift count sheet should not have been signed without a dual count at the time of shift change.