Failure to Properly Reconcile Controlled Medications During Shift Changes
Penalty
Summary
The facility failed to ensure proper pharmacy procedures were followed regarding the reconciliation of controlled medications during shift changes and when medication cart keys were exchanged between nurses. Specifically, the required process of conducting a physical inventory of all controlled substances with two licensed nurses at each shift change or key exchange was not consistently performed. Documentation revealed that on several occasions, only one nurse signed off on the reconciliation, and in some instances, the count was not performed at all when keys were handed over. This lapse in procedure was confirmed through review of shift-to-shift controlled medication reconciliation sheets, staff witness statements, and interviews. The deficiency was identified following an investigation into suspected tampering of liquid Morphine Sulfate bottles for two residents. One nurse discovered that a resident's Morphine Sulfate bottle was missing approximately 3.5 ml, and both this bottle and another resident's bottle had puncture holes in their seals, despite appearing otherwise unopened. The syringes for these bottles were still in their original packaging, indicating they had not been used for administration. Staff interviews revealed that several nurses who had access to the medication cart did not properly inspect the bottles or perform the required reconciliation counts, and some were unaware of the need to remove the lid and inspect the seal of liquid Morphine bottles. Further review of facility policy and state regulations confirmed that the facility was required to conduct a physical inventory of all controlled substances at each shift change or key exchange, with documentation by two licensed nurses. The investigation found that this policy was not followed, as evidenced by incomplete or missing signatures on reconciliation forms and staff statements admitting to not performing or witnessing the required counts. The failure to follow these procedures contributed to the inability to promptly detect and address the tampering and discrepancies in the controlled medication inventory.