Failure to Document Controlled Medication Counts per Policy
Penalty
Summary
The facility failed to implement its procedures for accurate documentation of controlled medications on one of three medication carts reviewed. According to the facility's policy, nursing staff are required to count controlled medications at the end of each shift, with both the oncoming and off-going nurses completing the count together and signing the record to verify accuracy. The policy also requires that any discrepancies be reported to the Director of Nursing Services immediately. However, a review of controlled drug records for the first-floor, back medication cart revealed multiple instances where the required signatures were missing. Specifically, on several dates, either the oncoming or off-going nurses, or both, failed to sign the narcotic count sheets as required. These findings were confirmed through staff interviews and review with the Director of Nursing. The lapses in documentation were directly observed in the narcotic sheets, and staff acknowledged that the required signatures were not present on the specified dates. The facility did not consistently follow its established procedures to ensure accurate documentation of controlled substances, as required by its own policy and state regulations.