Failure to Follow Controlled Substance Reconciliation Procedures
Penalty
Summary
The facility failed to implement its established pharmacy procedures for the reconciliation of controlled substances on one of five medication carts reviewed. According to facility policy, nursing staff are required to count controlled medications at the end of each shift, with both the on-coming and off-going nurses participating in the count and signing the verification sheet. A review of the controlled medication count sheet for Pavilion cart #2 revealed that on several occasions, the required signatures were missing during shift changes, specifically on multiple dates in July 2025. Observation of the medication cart and interviews with staff confirmed that licensed nurses did not consistently sign the count verification at the change of shift as required by policy. This failure to follow established procedures prevented timely identification of any discrepancies in controlled substance counts. The deficiency was identified through review of facility policy, controlled substance records, direct observation, and staff interviews.