Failure to Complete Shift-to-Shift Narcotic Reconciliation for Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliation was consistently completed for five out of six medication carts reviewed. During medication storage observations and record reviews, surveyors identified multiple instances across several units where the Controlled Drugs-Count Record lacked required signatures for shift-to-shift reconciliation of controlled substances. These omissions were noted on various dates and shifts, including day, evening, and night shifts, spanning several months and affecting the C Unit 1 and 2 hall carts, Advanced Acute Care Unit (AACU) cart, and both the short and long hall carts in the Acute Care Unit (ACU). Interviews with nursing staff and the Director of Nursing (DON) confirmed that the facility's expectation and policy require two licensed nurses to complete and sign the narcotic count at the start of each shift and during the exchange of keys. This process is intended to verify the accuracy of the controlled substance inventory and prevent drug diversion. However, the review of the Controlled Drugs-Count Records revealed numerous dates where this process was not documented as completed, indicating a failure to follow established procedures. The facility's policy, provided by the DON, outlines the requirement for clear, legible documentation of all controlled substances and mandates that two licensed nurses account for all controlled substances and access keys at the end of each shift. Despite this policy, the observed and documented lapses in shift-to-shift reconciliation demonstrate noncompliance with both facility policy and regulatory requirements for controlled substance accountability.