Failure to Maintain Accurate Controlled Substance Counts and Documentation
Penalty
Summary
The facility failed to maintain accurate records for controlled substances when shift-change narcotic counts were not completed and a narcotic count sheet for one resident was inaccurate. The facility’s policy required all controlled substances to be immediately added to the controlled substance log upon delivery, and required incoming and outgoing nurses or CMTs to count all Schedule II–V controlled substances at the beginning and end of each shift, documenting verification on the controlled substance log. The policy also required immediate reporting and investigation of any missing medications or discrepancies. For Resident #7, who had diagnoses including rheumatoid arthritis, chronic kidney disease, heart failure, low back pain, and diabetes, there was an active order for oxycodone-acetaminophen 10-325 mg to be given four times daily. During observation, a CMT opened the narcotic box, removed one oxycodone-acetaminophen tablet for the resident, and verified that four pills remained in the card. The CMT administered the medication but did not sign it out of the controlled substance book prior to administration, contrary to the facility’s expectations that narcotics be signed out immediately upon removal. When the CMT later went to sign out the dose, the controlled substance sheet showed a previous quantity of six pills, with one signed out for a total of five, while the actual card contained only four pills. The CMT reported that he/she had arrived late and the narcotic counts were not done at the start of the shift. The LPN on duty stated that counts should be done at the beginning and end of each shift but had assumed, without verifying, that the counts were completed. The DON and Administrator both stated they expected staff to complete shift-change counts and to sign out narcotics immediately upon removal, but these processes were not followed in this instance, resulting in an inaccurate narcotic record and inability to reconcile the controlled substance count.
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