Failure to Complete Shift-to-Shift Controlled Substance Counts
Penalty
Summary
The facility failed to ensure that two licensed personnel conducted a physical inventory of controlled substances at each change of shift, as required by facility policy. During a review of the medication cart and Controlled Substances Check Form for April 2025, multiple instances were identified where the required initials of the nurses coming on and going off shift were missing. Specifically, there were several dates where either the 'Nurse's Initials On' or 'Nurse's Initials Off' boxes were left blank, indicating that the controlled substances were not reconciled at the end and beginning of those shifts. Interviews with nursing staff and the Director of Nursing confirmed that the expectation is for both the incoming and outgoing nurses to count the narcotics together and document their initials on the form if the count is correct. The facility's policy and job descriptions for both Registered Nurses and Licensed Practical Nurses require accurate documentation and reconciliation of narcotic records for each shift. The failure to complete these checks and documentation affected four out of eighteen residents who were prescribed controlled substances from the second-floor long hall medication cart.