Failure to Properly Count and Document Controlled Narcotic Medication
Penalty
Summary
The facility failed to ensure that controlled narcotic medications were properly counted and documented by nursing staff for one resident who was admitted on hospice care and had a physician order for Morphine Sulfate. The resident's controlled substance record indicated that a 5ml bottle of Morphine Sulfate was received, but no doses were administered according to the medication sheet. Subsequently, the bottle and its count sheet went missing, and there was no record of the medication being signed out on the master count sheet. Interviews with nursing staff revealed that the required shift change counts of controlled substances were not consistently performed or documented, with several shift changes lacking any recorded counts for the medication cart. The Director of Nursing confirmed that the bottle and count sheet were last seen during a morning count and later found the count sheet in the shred bin, still intact and unsigned for any doses. Further review of the facility's procedures and interviews with staff indicated that the process for counting and documenting controlled substances at shift change was not followed as required. The facility's policy mandates that two licensed nurses account for all controlled substances at the end of each shift, but gaps in documentation and missing counts were identified. The failure to perform and document the narcotic counts as required led to the loss of the Morphine Sulfate bottle and its associated count sheet, with no explanation or record of its disposition.