Medication Labeling and Narcotic Count Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and documentation practices for medications and controlled substances. During an observation, an insulin pen (Lantus) was found in a medication cart without a resident's name on the label, which was confirmed by an LPN who acknowledged that the pen should have been labeled. Additionally, review of the narcotic count sheets for two medication carts revealed multiple instances where required signatures from both oncoming and off-going nursing staff were missing during shift changes. These omissions were noted on several dates for both the boardwalk south and 200 south medication carts. Interviews with nursing staff confirmed that the narcotic count sheets are expected to be signed at every shift change, as outlined in the facility's own policies. The policies require each prescription medication to be labeled with the resident's name and mandate that both oncoming and off-going staff sign the narcotic count sheets to verify reconciliation of controlled substances. The deficiencies were identified through direct observation, record review, and staff interviews.