Failure to Properly Track and Secure Controlled Medications on Medication Cart
Penalty
Summary
The facility failed to ensure controlled medications were properly tracked and secured from potential theft or diversion for one of two medication carts reviewed. During a medication cart audit conducted on 1/21/26 at 12:46 PM, surveyors observed narcotic accountability sheets dated 1/1/26 to 1/21/26 that were missing three licensed nurse signatures on 1/8/26 and 1/13/26. At 12:48 PM, a registered nurse stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart. At 1:07 PM, the DON confirmed that two nurses were expected to sign the narcotic accountability record when accepting or releasing the medication cart. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medications in the facility. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to the facility’s process for documenting and securing controlled medications on the medication cart.
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