Inaccurate Controlled Substance Documentation and Narcotic Count Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and timely documentation and accountability for controlled substances, including failure to follow its own narcotic counting and documentation policies. During review of the B/C hall Narcotic Book, the Shift Change Controlled Substance Inventory Sheet for a morning shift change was found to be signed only by the oncoming day nurse; the off‑going night LPN did not sign the form as required. The Assistant DON confirmed that both nurses are required to participate in the narcotic count and sign the sheet at shift change to verify the counts are correct. Further review of controlled substance documentation showed that an LPN pre‑signed controlled medications as if administered before actually giving them. For one resident’s hydrocodone/APAP (Norco), the Controlled Substance Proof of Use form was not in the narcotic book but on the nurse’s desk and showed the 11:00 a.m. dose of two tablets signed out, bringing the count to zero, even though the medication had not yet been given. For another resident’s pregabalin (Lyrica), the card contained 16 pills, but the Proof of Use form showed the 12:00 p.m. dose already signed out, reducing the documented count to 15. The LPN confirmed she had signed out these controlled medications ahead of time and acknowledged she knew this was not permitted. For a third resident receiving liquid morphine 100 mg/5 ml, there were multiple discrepancies between the amount documented on the Controlled Drug Receipt/Record/Disposition Form, the actual volume in the bottle, and the MAR and progress notes. At the time of reconciliation, the bottle contained 24 ml, while prior entries showed inconsistent volumes and missing or incorrect subtractions, including an instance where the documented remaining volume did not mathematically match the dose given and no explanation was recorded. Several doses were signed out on the controlled drug record on specific dates but were not documented as administered on the MAR, and in some cases there were no corresponding progress notes. A later “count correction” entry changed the documented volume from 25 ml to 24 ml without any recorded administration between those dates, and staff acknowledged they had attempted to clarify the amount in the bottle due to apparent subtraction errors. The Administrator and Assistant DON confirmed that the MAR and narcotic sheet should match for controlled medication administration and that these discrepancies should have been identified.
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