Failure to Document Controlled Drug Shift Counts on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper pharmaceutical services and controlled substance accountability on one of four medication carts reviewed, specifically the Medication Cart on Hall 100. Record review of the controlled medication count sheet for this cart showed missing signatures for both off-duty and on-duty nurses at shift changes on four separate dates (02/03/26, 02/06/26, 02/08/26, and 02/12/26). The facility’s policy, dated 01/15/25 and titled “Medication Management Program,” requires that controlled substances be counted by authorized staff at each change of shift and accounted for on a controlled substance record. The absence of required signatures indicated that the facility did not consistently document that these counts were completed as required. During interviews, the DON stated that staff were trained to perform controlled drug counts at the beginning and end of their shifts on their assigned medication carts and that nurses were expected to sign the medication count sheet after completing the count with the incoming or off-going nurse. The DON also stated that missing signatures meant she could not prove that the staff had successfully completed the counts. An LVN assigned to the Hall 100 cart acknowledged that she did not sign the medication count sheet on the identified dates, explaining that she found the layout of the sheet confusing because she had to sign on different sides and lines when signing on and off. She stated that she understood the importance of signing the sheet as proof that the count was done and reported that she did perform the counts as required, but failed to document them with her signature.
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