Failure to Complete Controlled Substance Reconciliation Logs at Shift Change
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled for two of six medication carts reviewed. During observations of the 500/600 hall PO cart and the 100/200/600 hall PO cart, sample inventories of controlled medications showed no discrepancies between the quantities documented on individual controlled substance logs and the actual number of pills present. However, review of the comprehensive controlled medication reconciliation logs used for cart audits during shift changes revealed missing signatures: two signatures were absent on the 500/600 hall PO cart log, and one signature was missing on the 100/200/600 hall PO cart log. Interviews with nursing staff and facility leadership confirmed the expectation that the controlled substance reconciliation logs should be signed by both the staff member relinquishing and the staff member taking control of the cart at each shift change. The facility's policy requires a physical inventory of all controlled medications at each shift change, conducted by two licensed nurses or a nurse and a qualified medication aide, with documentation on an audit record. The absence of required signatures indicated that the reconciliation process was not consistently followed as outlined in facility policy.