Failure to Accurately Document Controlled Substances in Narcotic Book
Penalty
Summary
Facility staff failed to maintain accurate records of controlled substances on the 5th Floor Unit, as required by both facility policy and federal and state regulations. Specifically, when new controlled medications were entered into the Controlled Substance Register (Narcotic Book) or when information for a medication was transferred from one page to another, staff did not complete the required documentation. The headings of each page in the register were missing critical information such as prescription numbers, fill dates, and transfer page numbers. This was confirmed during a review of the Controlled Substance Log by a surveyor and a nurse, who found that none of the reviewed pages had the necessary information filled in. Interviews with both a nurse and the Director of Nursing (DON) confirmed that the facility's procedures require the prescription number and date filled to be logged and transferred appropriately when a new page is started in the Controlled Medication Log. However, these steps were not followed, resulting in incomplete documentation for controlled substances. The deficiency was limited to the 5th Floor Unit out of four units reviewed, and no specific residents or patient conditions were mentioned in relation to the deficiency.