Failure to Accurately Reconcile and Document Controlled Medications
Penalty
Summary
The facility failed to establish and maintain accurate systems for reconciling controlled medications according to acceptable standards of practice. During a review of the narcotic books, it was found that one out of four narcotic reconciliations was inaccurately documented. Specifically, a registered nurse signed for both the on-coming and off-going shifts, with the off-going shift signature being inaccurate. The nurse reported that this was how she was trained during orientation and appeared confused about the importance of accurate narcotic shift count documentation. Further review by the unit manager confirmed the early and inaccurate documentation of the nurse's initials on the narcotic sheet. The facility's policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, but this standard was not followed. The Director of Nursing acknowledged that the facility's narcotic reconciliation practice did not meet acceptable standards.