Inaccurate Documentation of Narcotic Shift Change Counts
Penalty
No penalty information released
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Summary
Staff failed to accurately document medical records related to controlled substances. On one shift, a staff member worked from 2:00 p.m. to 10:00 p.m. and signed the Controlled Drugs-Count Records at the 2:00 p.m. shift change, indicating all narcotics were accounted for. However, at the 4:00 p.m. shift change, the same staff member handed over the medication cart keys to another LPN without completing the required narcotic count together. Both staff members later acknowledged in interviews that the shift change narcotic count was not performed as required, despite both signing the record to indicate it had been completed. The documentation did not accurately reflect the actual events, resulting in inaccurate medical records.