Failure to Accurately Account for and Administer Controlled Medications
Penalty
Summary
The facility failed to implement and follow procedures for the accurate accounting of controlled medications on two medication carts, as required by facility policy. Review of controlled substance count logs revealed that on multiple occasions, both oncoming and outgoing nurses did not sign the verification sheets during shift changes to confirm the counts of controlled drugs. This lapse was confirmed by staff interviews, with LPNs noting that agency and night shift staff often neglected to complete the required counts and documentation. Additionally, the facility failed to ensure the accurate administration of medications, resulting in a medication error for one resident. The resident, who had diagnoses of anxiety, depression, and a history of falls, was prescribed lorazepam 0.5 mg three times daily. On one occasion, the resident received two doses of lorazepam in the morning—once at 7:00 a.m. and again at 10:00 a.m.—due to a lack of communication and documentation between shifts. The error was discovered when staff realized the medication had been signed out and administered twice, with no clear record of the first administration or proper handoff between nurses. Staff interviews and witness statements indicated confusion and lack of clarity during shift changes, with one LPN admitting uncertainty about whether the medication was actually given. The incident was documented in the resident's clinical record, and the nursing home administrator confirmed the facility's failure to follow procedures for controlled medication accounting and administration, resulting in the identified medication error.