Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to maintain an adequate system for the receipt and disposition of controlled drugs, resulting in the inability to accurately reconcile and account for all controlled substances. Specifically, staff did not consistently sign out or count narcotics during shift changes on multiple medication carts. For one resident, a nurse administered hydrocodone/acetaminophen but did not document the administration on the narcotic count sheet for two consecutive night shifts. This led to a discrepancy in the medication count, with one tablet unaccounted for until it was verbally confirmed by staff that the medication had been given. Observations and interviews revealed that medication aides and nurses did not perform required narcotic counts together during shift changes on several occasions. Staff members reported that if a medication aide was not present, the nurse should count with another nurse, but this protocol was not consistently followed. Review of narcotic count sheets showed numerous missing signatures for both off-going and on-coming shifts across three different medication carts throughout the month, indicating a pattern of noncompliance with established procedures. The facility's policy required that controlled substances be counted at the end of each shift by both the off-going and on-coming staff, with any discrepancies reported to the director of nursing. However, the director of nursing and the administrator were unaware of the extent of missing signatures and incomplete counts until the issue was brought to their attention. The lack of proper documentation and shift-to-shift reconciliation created gaps in the facility's ability to ensure the security and proper administration of controlled medications.