Failure to Follow Narcotic Count and Documentation Procedures
Penalty
Summary
The facility failed to follow its policy and procedure for accounting for narcotic controlled substances, specifically regarding the verification and documentation of liquid Ativan for a resident with an anxiety disorder. During an end-of-shift narcotic count, two LPNs did not have the narcotic count sheet present while verifying the amount of liquid Ativan stored in the medication room refrigerator. Instead, one nurse relied on memory and prior knowledge of the count, and both nurses acknowledged that the narcotics book should have been with them to accurately verify the medication, resident, and remaining amount. The Director of Nursing confirmed that the expectation was for nurses to have the narcotics sheets present during the count to ensure accuracy. Additionally, a review of the facility's Narcotic and Controlled Substance Shift-to-Shift Count Sheet for a specific month revealed multiple instances where either the off-going or on-coming nurse did not sign the sheet after completing the shift-to-shift narcotic count. Interviews with registry nurses indicated that they were unaware of the requirement to sign the count sheet, and in some cases, the sheet was not available for signature. Both nurses confirmed that the medication count was performed, but the required documentation was not completed. The facility's policy requires that controlled substances be counted at the end of each shift by both the off-going and on-coming nurses, with both individuals signing the designated record. The policy also states that any discrepancies should be reported to the Director of Nursing. The observed failures included not having the narcotics sheet present during the count and not signing the shift-to-shift count sheet, which were confirmed by staff interviews and record review.