Inaccurate Narcotic Count and Reconciliation
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards, specifically in the accurate counting and reconciliation of controlled substances. During a survey, it was observed that the Individual Patient Controlled Substance Administration Record (IPCSAR) reconciliation sheet was incorrect for eight shifts with 16 occurrences on Medication Cart A, 2nd floor. The surveyor noted that a tablet of Oxycodone/Acetaminophen 5/325 mg was missing from the blister pack, despite the IPCSAR indicating one tablet should remain. The December 2024 Medication Administration Record (MAR) showed the missing pill was administered and signed off on the resident's MAR but not correctly on the IPCSAR. Further investigation revealed discrepancies in the Narcotic Shift Count log, with inaccurate counts recorded for multiple shifts and missing reconciliation signatures for the 11pm-7am shift on 12/4/24. Interviews with the LPN/UM and the DON confirmed that the facility's policy for narcotic counts during shift changes was not followed. The facility's policy requires controlled substances to be accounted for by two licensed nurses at the end of each shift, which was not adhered to, leading to the identified deficiencies.
Plan Of Correction
1. Resident affected by the deficient practice: The facility failed to provide pharmaceutical services in accordance with professional standards to ensure dispensed and administered controlled substance medication was accurately counted, and the individual patient NJ Ex Order 26.4(b)(1) administration record sheet was incorrect for 8 shifts with 16 occurrences on medication Cart on the floor. Investigation was initiated. Nurse who signed MAR was interviewed and indicated that medication was administered but was not documented on Individual Patient Controlled Substance Administration Record (IPSCAR). Individual nurse who did not accurately document on IPSCAR received in person education on the Controlled Substance Administration and Accountability Policy. Nurses who completed the shift counts for 12/2/24 (11pm-7am shift), 12/3/24 (11p-7am, 7a-3p, and 3p-11p), 12/4/24 (11p-7a, 7a-3p and 3p-11p) and 12/5/24 (11p-7a and 7a-3p) received in person education on the Controlled Substance Administration and Accountability. 2. Identifying other residents who could be affected by the deficient practice: Residents who receive narcotic medication could be affected by this deficient practice. 3. Measures or systemic changes to ensure that the deficiencies will not recur: Licensed Nurses received in person education on the Medication Administration Policy and the process of end of shift narcotic count by Director of Nursing / Designee by reviewing the Medication Administration Policy and the end of shift count with the Nurses. 4. Monitoring the continued effectiveness of the systemic change: The Director of Nursing or Designee will complete an audit of all narcotic count sheets to ensure accuracy weekly x4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.