Incomplete Controlled Drug Count Documentation by Nursing and Medication Staff
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate controlled drug count records and to ensure that all staff responsible for controlled medications signed the controlled drug count sheets as required. Review of controlled drug count sheets for multiple halls and shifts in January and February showed missing signatures from several LVNs and a medication aide on dates and shifts when they had responsibility for the medication carts. The controlled drug count forms stated that signing acknowledges the staff member has counted the controlled drugs on hand and verified that the quantity matches the Controlled Drug Administration Record, but these signatures were absent on numerous shifts across different halls. Interviews with involved nursing staff confirmed that they understood they were responsible for signing the controlled drug sheets at the beginning and end of their shifts to document that they had counted and assumed responsibility for the controlled medications. One LVN stated she had counted the controlled medications on the identified dates but could not recall why she did not sign the sheets, acknowledging that she had been trained to sign when coming on and leaving her shift. Another LVN reported that she had counted the drugs on the listed dates and attributed the missing signatures to forgetting after working double shifts, while stating that her narcotic counts had always been accurate. A third LVN similarly stated she always counted the controlled medications before taking responsibility for them but could not recall why she did not sign on the specified dates. Additional attempts to interview a medication aide and another LVN involved were unsuccessful. The DON stated that nurses and MAs were expected to sign in and out on the controlled drug sheets to ensure controlled drugs were being counted accurately and acknowledged that she and the ADON were responsible for reviewing the sheets twice weekly, but that the sheets had been overlooked while she was adjusting to her role. The Administrator also stated that all nurses and MAs were responsible for signing in and out on the controlled drug count sheets. The facility’s written policy on controlled substances required nursing staff to count controlled medications at the end of each shift, with the oncoming and offgoing nurses counting together and documenting the count, and using these records to reconcile inventory and identify loss or potential diversion. The report notes that this failure could place the facility at risk for drug diversion.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.