F0755

D

Failure to Accurately Reconcile and Document Controlled Substances

El Paso, Texas Survey Completed on 12-04-2025

Penalty

No penalty information released

Summary

The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of drugs and biologicals, and failed to maintain an established system for accurate reconciliation of controlled substances on one of two medication carts (East Wing). Record review of the Controlled Substance Shift Change Audit Record for the East Wing medication cart dated 12/03/25 showed only one nurse’s signature documented for the 2:00 PM shift change. During interview, the LVN who signed the form stated she had signed it at the 2:00 PM shift change but could not explain why it appeared to have been signed ahead of time. The facility’s policy required a physical inventory of all Schedule II controlled medications at each shift change or when keys were rendered, to be conducted by two licensed nurses and documented on the controlled substances accountability record or verification of controlled substances count report.

In interviews, the DON stated that nurses were responsible for performing the narcotic count and signing the form during the change of shift only after the count was completed, and acknowledged that signing ahead of time posed a risk for drug diversion and residents not having access to their medications. The DON was unable to recall the last in-service regarding narcotic counts and stated she monitored the count sheets up to twice weekly. An RN similarly stated that the narcotic count sheet was used by nurses to ensure accuracy of medications counted during shift change, that the DON was responsible for auditing the sheets as often as possible, and that signing the count sheet ahead of time could result in residents not having medications available and posed a risk of drug diversion. The RN was also unable to recall the last in-service on this process.