Failure to Document and Verify Narcotic Counts at Shift Change
Penalty
Summary
The facility failed to ensure that narcotic counts were properly documented and initialed by both the on-coming and off-going nurses at each shift change for all eight medication carts reviewed. According to the facility's policy, nursing staff are required to count controlled medication inventory at the end of each shift, reconcile the inventory count, and document their initials to confirm the count. However, multiple instances were identified where either the on-coming or off-going nurse, or both, did not initial the narcotic count or document the number of narcotic cards present in the narcotic drawer as required. These lapses were observed across various medication carts and on multiple dates, with missing documentation and initials noted on the narcotic sheets. Interviews with nursing staff revealed a lack of awareness or adherence to the documentation requirements, with one LPN stating that the omission was a mistake due to unfamiliarity with the shift. Another nurse did not provide an explanation for the missing documentation. The Director of Nursing confirmed the presence of blanks in the narcotic sheets and acknowledged that staff are expected to count and document the narcotics at each shift change. The failure to consistently document and verify narcotic counts as per policy was observed throughout the facility.