(a)

1. (1) There shall be a count of all CII controlled medications at each change of shift.
2. (2) All Schedule III, Schedule IV, and Schedule V controlled medications should be counted at least once daily unless a true unit dose system is used.
3. (3) This counting shall be made by the off-going charge nurse and the on-coming charge nurse.
4. (4) If licensed personnel are not available on a shift, a nonlicensed employee can co-sign as a witness with the off-going nurse and co-sign as a witness again with the on-coming nurse.
5. (5) This counting shall be documented.
6. (6) This documentation shall include the date and time of the count, a statement as to whether or not the count was correct, and if it was incorrect, an explanation of the discrepancy.

(b)

1. (1) This record shall be retained by the facility as a permanent record and be readily retrievable.
2. (2) 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.
3. (3) Also, a copy of the form for reporting theft or loss of controlled substances should be mailed to the Division of Pharmacy Services and Drug Control of the Department of Health.
4. (4) All documentation must be retained in the facility as a permanent record.