Narcotic Reconciliation Deficiency
Penalty
Summary
The facility failed to ensure the completion of narcotic reconciliation records, as evidenced by missing signatures and initials on the narcotic count sheets for three medication carts reviewed. This deficiency was identified during a review of facility records and staff interviews. The facility's in-service policy, implemented in October 2024, requires nursing staff to count controlled medications at the end of each shift, with both the oncoming and outgoing nurses participating in the count. However, observations on April 24, 2025, revealed multiple missing signatures for oncoming and outgoing nurses on the narcotic reconciliation sheets for the 2nd Floor Medication Cart and two medication carts on the 3rd Floor. Licensed Practical Nurses (LPNs) confirmed the missing signatures during the observations. Specifically, LPN Employee E9 confirmed the missing signatures on the 2nd Floor Medication Cart, while LPN Employees E10 and E20 confirmed the missing signatures on the two 3rd Floor Medication Carts. An interview with the Clinical Regional Nurse, Employee E13, further confirmed the missing signatures and initials on the narcotic reconciliation sheets. This failure to maintain accurate narcotic reconciliation records is a violation of the facility's procedures and regulatory requirements.
Plan Of Correction
A - N/A B - Narcotic reconciliation records audited for missing signatures. C - All nurses educated on Narcotic count and reconciliation process. D - Weekly x 4 then monthly x 2 audits by DON or designee of narcotic counts and reconciliation to ensure completion. Results discussed during QAPI meetings.