Failure to Accurately Account for Controlled Substances in Narcotic Ledgers
Penalty
Summary
The facility failed to ensure the accuracy of Narcotic Ledgers for two medication carts, resulting in discrepancies in the accounting of controlled substances. According to facility policy, a physical inventory of controlled medications was to be conducted by two licensed staff at each shift change, with documentation on the record and immediate reporting of any discrepancies to the Director of Nursing. However, observations and record reviews revealed that the required procedures were not consistently followed. On one cart, a review of the Narcotic Ledger showed 21 tablets remaining on a page, but the corresponding medication card was missing from the cart. A registered nurse admitted to not catching the missing card during the shift count and stated that only the physical cards in the lock box were counted, rather than verifying each page of the ledger as required. On another cart, multiple pages in the Narcotic Ledger showed transfers of controlled medications to other units with only one nurse's initials, rather than the required signatures of both the releasing and receiving nurse. Several pages also lacked medication names, prescription numbers, or proper identification of the medication form, and some pages had no nurse signature for medication card transfers. Interviews with nursing staff confirmed that the expected process of going page by page in the Narcotic Ledger to ensure all controlled medications were accounted for was not followed. Staff acknowledged the importance of this process in preventing narcotic diversion and ensuring accurate accounting of controlled substances, but admitted to not adhering to the established procedures. The Director of Nursing also confirmed the expectation for both nurses to sign the ledger during transfers and for staff to verify each page during counts.