Failure to Consistently Complete Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its policy and procedure for medication storage, specifically regarding the completion of Narcotic Count Check Sheets (NCCS), was consistently followed. Record review revealed that, across several months, there were multiple instances where either one or no licensed nurses signed the NCCS at required times, despite the policy mandating that two licensed nurses verify and sign the count at each shift change. Specific dates were identified where signatures were missing or incomplete, indicating that the required physical inventory of controlled medications was not properly documented. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that two nurses are responsible for counting narcotics and signing the NCCS at the beginning and end of each shift. The facility's policy also requires this process to be documented for all controlled substances in accordance with federal and state regulations. The observed lapses in documentation and missing signatures on the NCCS represent a failure to adhere to these established procedures.