Failure to Complete Controlled Substance Shift-to-Shift Reconciliation Logs
Penalty
Summary
Surveyors observed that the facility failed to ensure proper completion of controlled substance shift-to-shift reconciliation sign off sheets for all four medication carts reviewed. Specifically, numerous required signatures were missing from the controlled substance logs for both July and August 2025 across multiple units. For example, on the 2-east medication cart, 31 out of 186 possible signatures were missing for July, and 20 out of 74 were missing for August. Similar deficiencies were found on the 2-west, 3-east, and 3-west medication carts, with missing signatures ranging from 9 to 61 per log. Interviews with nursing staff and the Director of Nursing confirmed that it is facility policy for both the off-going and oncoming nurses to count controlled substances together and sign the log at each shift change, but staff were unable to explain the missing signatures. Review of facility policy dated August 1, 2024, confirmed the requirement for incoming and outgoing nurses to count all schedule two controlled substances and other medications with a risk of abuse or diversion at each shift change or at least once daily, and to document the results on a verification sheet. Despite this policy, the observed logs showed consistent non-compliance, with staff acknowledging the process but not adhering to the documentation requirements. No explanation was provided for the missing signatures, and the deficiency was identified solely through observation and staff interviews. No specific residents or patient conditions were mentioned in relation to the deficiency.