Failure to Accurately Account for Controlled Medications on Medication Carts
Penalty
Summary
The facility failed to implement its own procedures for the accurate accounting of controlled medications on two medication carts, specifically the Cardinal East and Cardinal Southwest carts. According to the facility's policy, controlled medications are required to be counted by two professional nurses at the beginning and end of each shift, with documentation of the count and signatures to verify accuracy. However, a review of the narcotic count record logs revealed that nursing staff did not sign the records during shift changes on multiple occasions for both medication carts. Specific dates were identified where outgoing nurses failed to sign off, indicating that the required verification of controlled drug counts was not completed as per policy. Interviews with LPNs confirmed that there was no alternative method in place to verify narcotic counts other than the paper log, and that the required documentation was not completed. The deficiency was communicated to the Nursing Home Administrator, confirming that the facility did not follow its established procedures for controlled medication management as required by state regulations.