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Nurse altered my controlled medication count

by DJP417 DJP417 (New) New

I am a nurse working in a personal care home in Georgia. I am the only nurse in the facility during my shift and there are several hours per day where shifts are not connected, so we do not have a nurse to relieve us. We just leave at our scheduled time. This also means that we count controlled meds alone without a witness.

Yesterday when I arrived to work, I noticed that the agency nurse who worked earlier that day had logged her beginning counts for all of the controlled meds but forgot to log the counts at the end of her shift. I also noticed that the count was off (one too many pills), indicating to me that the nurse gave the client one too few pills, even though she charted otherwise in the MAR. I just figured I would file a medication variance report with my supervisor and that would be the end of that.

To my surprise, when I returned to work today (following the shift of the same nurse as the day before), I see that she had filled in the blank spaces on the controlled count from the day before, saying that she gave the 2 pills as ordered (vs the 1 she actually gave) -- but here's the kicker: my count from the day before was altered to make her count look correct. She changed the number 41 that I had written in the log into a 40 (you can tell that it's been altered when you look at it). This also means that she would have to have gotten rid of an extra pill (either by taking, wasting, or administering incorrectly). I also rolled back the cameras to make sure that she was the only person who entered the locked med room during the time between my shifts.

Anyway, I reported this to my supervisor, who typically doesn't do much about anything when I report it. I am concerned that nothing will come of this. Normally I would not care too much, but I feel like I need to take ownership of this because it involves my signature and my license. She is licensed in the state of Florida but working in Georgia due to the compact. Does anyone have advice? Should I report this? If so, do I report it to the GA or FL BoN?

I would begin by filling out a second incident report related to the alteration of your documentation. When you do that I'd contact your supervisor to discuss the matter. "I'm filling out a second incident report and I'm pretty disturbed that my entry has been altered. That is not okay."

I'll refrain from an opinion about reporting for now; ideally if there is a concern about controlled substance discrepancy this is investigated by the employer and appropriate actions taken. If your goal is to protect yourself, I'm not sure that reporting her through outside channels protects you any more than reporting through your internal processes (neither of which protect you very much in this kind of situation).

Hope it gets sorted out.