The facility did not follow its policy requiring two licensed nurses to reconcile and sign for controlled medications at each shift change on one medication cart. During a medication cart audit, surveyors found multiple narcotic audit shift count sheets with only one nurse signature for several shift counts. An LPN and the DON both confirmed that two nurses were required to sign when accepting or releasing the medication cart, but this had not occurred. This lapse in documentation and reconciliation affected controlled medications for residents receiving these drugs.
The facility failed to maintain secure medication storage and control. A resident with multiple serious medical conditions was found storing and self-administering Lactaid from a bedside nightstand without a corresponding physician order on the MAR. In a separate instance, an LPN left a medication cart unattended with a medication cup containing a pill on top of the cart while entering a resident’s room, and acknowledged this was improper.
The facility failed to follow its policy requiring two nurses to count and document controlled substances at each shift change, resulting in missing nurse signatures on narcotic count sheets for both medication carts reviewed. During audits of two halls, surveyors found multiple dates where only one or no licensed nurse signatures were recorded on Narcotic Card Item Count sheets, despite the expectation that two nurses sign when accepting or releasing the cart. An LPN on each hall and the DON confirmed that two signatures were required but not consistently obtained, affecting all residents receiving controlled medications.
Surveyors identified that controlled medications were not consistently tracked according to facility policy, as narcotic accountability sheets for two medication carts were missing required dual nurse signatures on multiple occasions. During audits, staff, including an RN and the CNO, acknowledged that two nurses were supposed to sign the narcotic sheets when accepting or releasing the med carts, but this did not always occur, affecting all residents receiving controlled meds.
Surveyors identified that controlled medications were not properly tracked on two medication carts, as required narcotic accountability sheets were missing one of the two licensed nurse signatures on multiple dates. An LPN and the DNS both confirmed that two nurses were supposed to sign the narcotic sheets when accepting or releasing the carts, but this did not occur as required. This documentation failure involved carts used for residents receiving controlled medications and created the potential for undetected misuse or diversion.
Surveyors identified that controlled medications on one medication cart were not properly tracked when narcotic accountability sheets showed only one nurse signature on a specific date instead of the required two. An LPN and the DON both acknowledged that two nurses should sign the narcotic sheet when accepting or releasing the cart, but this did not occur, affecting all residents receiving controlled medications from that cart.
Surveyors found that controlled medications on one medication cart were not properly tracked or secured when narcotic accountability sheets were missing required nurse signatures on multiple days. An RN and the DON both stated that two nurses were expected to sign the narcotic accountability records when accepting or releasing the cart, but this did not occur as required, creating the potential for undetected misuse or diversion of controlled medications affecting all residents receiving these drugs.
A resident with iron deficiency anemia and a right humerus fracture had a physician order for daily Ferrous Gluconate for supplementation, but the medication was not administered as ordered. During a med pass, a MAC reported the iron supplement was not available, and further review showed the order had been in place for an extended period without doses given. The DON later stated the medication had been obtained but was not moved to the resident’s new med cart after a room change, resulting in ongoing failure to provide the ordered iron therapy.
Surveyors found that controlled medications were not consistently tracked according to facility practice on two of three medication carts. During audits of two hall carts, narcotic accountability sheets covering several days were missing one of the two required licensed nurse signatures. A CMA and an LPN each stated that two nurses should sign the narcotic sheets when accepting or releasing the carts, and the DON confirmed this requirement. The missing signatures showed that dual-nurse verification of controlled medications was not reliably completed, affecting all residents receiving controlled drugs.
Controlled medications were not properly tracked and secured when a narcotic accountability sheet for a medication cart was missing a required nurse signature on one date. Staff confirmed that two nurses should have signed the sheet when accepting or releasing the cart, but this was not done as required.
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