Inadequate Medication Reconciliation System for Non-Narcotic Controlled Medications
Penalty
Summary
The facility failed to ensure an adequate system for medication reconciliation to timely identify loss or diversion of non-narcotic, controlled medications across all medication carts reviewed. Observations and interviews revealed that non-narcotic, controlled medications were stored in permanently affixed lock boxes within locked medication carts, and staff reconciled these medications every shift using a three-ring binder with loose, three-hole punched paper. Staff members confirmed that the reconciliation process involved comparing the count of medications in the locked box to the corresponding sheet in the binder, and referencing the medication administration record if discrepancies were noted. However, staff also acknowledged that the use of loose paper in a three-ring binder made it difficult to detect if a medication sheet and the corresponding medication card were removed, as there was no way to tell when a sheet was missing until the next administration of the medication. The director of nursing (DON) and multiple staff members confirmed that the current practice did not provide a reliable method for timely identification of missing or diverted non-narcotic, controlled medications. The facility's policy required shift change counts and documentation on a controlled drug record and a C-drug Count Acknowledgement Form, but did not specify the use of a bound book or other secure method for recordkeeping. Staff expressed uncertainty about how they would notice if documentation or medication was removed, relying instead on memory or familiarity with the medications. This system limitation was observed on all floors reviewed, and the DON acknowledged the inadequacy of the current practice for tracking and reconciling non-narcotic, controlled medications.