Failure to Properly Account for Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly accounted for in accordance with accepted professional standards. Review of controlled substance ledger books for three medication carts revealed numerous missing signatures on required end-of-shift narcotics counts. Specifically, for Medication Cart 1 on the first floor, 37 out of 75 signature lines were left blank over a period of several weeks. For Medication Cart 1 on the second floor, 93 out of 189 signature lines were missing, and for Medication Cart 2 on the second floor, 93 out of 189 signature lines were also missing. These omissions were confirmed by interviews with nursing staff responsible for the medication carts, who acknowledged the missing signatures and confirmed that the facility's process was to follow the standard practice of dual nurse verification and sign-off. Further, the Director of Nursing acknowledged the inconsistent accounting of controlled substances during an interview. The findings were based on both record review and staff interviews, and the facility's process was compared to established standards as described in a referenced professional article. No information was provided regarding specific residents affected, their medical histories, or their conditions at the time of the deficiency.