Controlled substances require secure storage, accurate count, proper administration documentation, shift-to-shift reconciliation, waste witnessing, discrepancy reporting, and timely investigation.
Nurse Responsibilities
- Count controlled medications at shift change with two licensed nurses when required.
- Sign controlled drug record accurately.
- Document administration immediately.
- Waste according to policy with witness.
- Report discrepancy immediately to supervisor/DON/designee.
- Never pre-sign, alter count sheets improperly, or delay discrepancy reporting.
CMS guidance includes review of controlled drug accounting, reconciliation, and documentation of controlled medication administration and resident outcomes.