Failure to Ensure Proper Controlled Substance Logbook Signatures at Shift Change
Penalty
Summary
The facility failed to ensure that the controlled substance logbook for one of four medication carts was properly signed by two licensed staff at each change of shift. During a review of the controlled substance logbook for cart #2 in the Catoctin unit, it was found that several entries were not in chronological order, some dates had only one signature from a licensed staff member, and some dates had no signatures at all. The logbook is intended to document the count and transfer of controlled substances between staff, and the expectation is that both the nurse counting out and the nurse counting in sign the log at each shift change. Interviews with an LPN assigned to the cart confirmed that nurses are responsible for signing the logbook whenever they take the keys for the cart, regardless of the time. The DON acknowledged the issues with missing signatures and explained that the responsibility for cart #2 was shared between two nurses, which may have contributed to the incomplete documentation. The findings were confirmed through review of the logbook and interviews with staff, including the DON.