Failure to Implement QA Plan for Narcotic Count Documentation
Penalty
Summary
The facility failed to ensure that its Quality Assurance Committee effectively implemented a developed plan of action to address identified quality deficiencies related to accurate narcotic count documentation. Despite creating a Quality Assurance Performance Improvement (QAPI) plan that included weekly audits of medication carts and required nurse signatures, recurring problems with incomplete and inaccurate narcotic reconciliation documentation persisted. The Director of Nursing confirmed that, although the issue was identified and interventions such as staff discipline were outlined, no disciplinary actions were taken against nursing staff for ongoing noncompliance, and the documentation issues continued to be observed during the survey.