(a)

1. (1) There shall be a count of all C-II controlled medications at each change of shift.
2. (2) All C-III, C-IV, and C-V controlled medications should be counted at least once daily unless a true unit dose system is used.

3. (3)

   1. (A) This count shall be made by the off-going charge nurse and the oncoming charge nurse.
   2. (B) If licensed personnel are not available on a shift, a nonlicensed employee can cosign as a witness with the off-going nurse, and cosign as a witness again with the oncoming nurse.

4. (4)

   1. (A) This count shall be documented.
   2. (B) This documentation shall include:

(i) The date and time of the count;

1. (ii) A statement as to whether or not the count was correct; and

   1. (iii) If it was incorrect, an explanation of the discrepancy.
   2. (C) This record shall be retained by the facility as a permanent record and be readily retrievable.

(b)

1. (1) When loss, suspected theft, or an error in the administration of controlled drugs occurs, it must be reported to the director of nursing services and an incident report filled out.

2. (2) Also, a copy of the form for reporting theft or lost controlled substances should be mailed to the Division of Drug Control of the Department of Health.

   1. (c) All documentation must be retained in the facility as a permanent record.

      1. (d)
3. (1) When a dose of a controlled drug is dropped or broken, two (2) people should make a statement in the bound ledger as to what occurred, and both must sign their names.
4. (2) These two (2) people shall be licensed nursing personnel, whenever possible.