Failure to Maintain Accurate Controlled Substance Inventory Records
Penalty
Summary
The facility failed to maintain accurate and thorough records of receipt and disposition of controlled substances, as required by both federal and state regulations. Review of the facility's policies indicated that controlled substances must be documented with the date, time, and signatures of the receiving personnel, and that shift change inventory counts must be verified and signed by two nurses. However, examination of the controlled substance inventory sheets for one of the two facility floors revealed multiple instances where only one nurse signature was present, or where there was no documentation of signatures at all for both morning and evening shift changes. There were also occasions where the total number of medication cards was inconsistent or not documented, and instances where medications were added without corresponding documentation of the resident or medication details. Interviews with staff confirmed that the expected practice was for two nurses to count and sign off on the narcotic inventory tracker at each shift change and whenever the narcotic box was accessed. One LPN stated that he/she always counted narcotics with another nurse and suggested that missing signatures were likely due to the other staff member forgetting to sign. The DON and Administrator both confirmed their expectation that two staff members sign off on every entry, both at shift changes and when the narcotic box was accessed for any reason. Despite these expectations, the documented records showed repeated failures to comply with the facility's own policy and regulatory requirements for controlled substance accountability. The lack of consistent dual signatures and incomplete documentation prevented accurate reconciliation of controlled substances, as required to ensure proper pharmaceutical services for residents. No specific residents were identified as being directly affected in the report, and the census at the time was 80.