Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to maintain effective systems for the accurate reconciliation and recordkeeping of controlled medications for one resident. Specifically, the controlled declining inventory sheet for a resident's Ativan 0.5mg tablets, received on a specified date, was missing and could not be located by the facility. The facility's policy required a separate, accurately maintained declining inventory record for each controlled substance, to be reconciled at each shift change by two licensed nurses and retained for at least three years. However, the required documentation for the resident's Ativan was not available for review, and the facility was unable to produce the sheet when requested. Interviews with staff revealed that a nurse discovered the resident's card containing 10 Ativan tablets was missing from the locked controlled substance drawer, while the inventory sheet remained in the nurse's book. The incident was reported to the DON, who confirmed the inventory sheet for the dispensed Ativan could not be found and acknowledged the requirement to retain such records. The missing medication was never recovered, and the resident did not recall missing any doses or having concerns about her medication. The administrator stated an expectation for accurate maintenance of controlled medication records in accordance with facility policy.