Failure to Reconcile and Document Controlled Medications in Emergency Kits and Medication Carts
Penalty
Summary
The facility failed to reconcile and account for five medication emergency kits (eKITs) containing controlled medications (CMs) for the months of November and December 2025. This deficiency was observed in three medication rooms and one medication cart, where accountability logs for the reconciliation of CM inventory at every shift change were missing. Additionally, there were discrepancies in the count of CMs, specifically lacosamide, in two medication carts for a resident with a seizure disorder. The counts in the medication bubble packs did not match the documentation on the accountability logs, and there was no record of subsequent administrations to explain the missing doses. During observations and interviews, it was revealed that licensed nurses administered doses of lacosamide but failed to sign off on the Antibiotic or Controlled Drug Record accountability logs as required by facility policy. Both nurses acknowledged that they did not follow the policy of signing each CM dose on the accountability log after preparing and administering the medication. The Assistant Director of Nursing and the Director of Nursing confirmed that the eKITs containing CMs were not reconciled at every shift change, and that the required accountability and reconciliation logs were not maintained for the specified period. The resident involved had a diagnosis of epilepsy and was prescribed lacosamide 200 mg twice daily for seizure disorder. The facility's policies required that all CMs, including those in emergency kits, be counted and documented at every shift change by two licensed nurses, and that administration of CMs be immediately recorded on the accountability record and the Medication Administration Record (MAR). These procedures were not followed, resulting in unaccounted doses and missing documentation for both individual resident medications and emergency kits containing controlled substances.