Failure to Properly Count and Document Controlled Medications on All Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of controlled medications for all four medication/nurse carts reviewed. During observations and record reviews, surveyors found that the controlled drug audit record for one medication cart lacked the oncoming nurse’s signature for the 6 a.m. to 6 p.m. shift, and another nurse cart’s record lacked the off‑going nurse’s signature for the overnight shift ending at 6 a.m. For two additional carts, the controlled drug audit records were pre‑signed for the upcoming 6 p.m. shift by the off‑going nurse before the end of the shift, rather than being completed at the time of the actual count at shift change. Staff interviews further demonstrated inconsistent and improper practices related to controlled medication counts and documentation. One LVN using a nurse cart stated she had not counted the cart medications and reported that another LVN was responsible for counting all carts at the start of the shift, a practice she was unfamiliar with as a new employee. When the narcotic log for a medication cart was reviewed and found unsigned for the beginning of the shift, the LVN identified as responsible for counting all carts acknowledged she had performed the count but had forgotten to sign the log, and she then signed it during the surveyor’s presence. A medication aide passing medications from that cart stated that narcotic counts were done at 6 a.m. by the nurse before her shift began, that she never counted the carts herself, and that staff handed off cart keys to others when going on break without completing a narcotic count before transferring possession. Interviews with leadership confirmed that facility expectations and policy were not being followed in practice. The DON stated that both off‑going and on‑coming nurses should count all narcotics on the carts and sign the narcotic count record at that time, but she was initially unsure whether pre‑signing the narcotic count record or handing off keys without a count was permitted and needed to check the policy. The Corporate Compliance Nurse later stated that staff should not pre‑sign narcotic count logs and should sign them at the time the cart is counted at shift change. Review of the facility’s written policy on controlled medications showed that only authorized licensed nursing and pharmacy personnel should have access to controlled medications, that the medication nurse on duty must maintain possession of the key, that a controlled medication accountability record must be completed when receiving and administering controlled medications, and that a physical inventory of all controlled medications must be conducted and documented at each shift change, with any discrepancies reported to the DON and investigated. These documented requirements contrasted with the observed and reported practices on the units.
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.