Failure to Document and Accurately Perform Narcotic Shift Counts
Penalty
Summary
The facility failed to ensure that at the completion of the narcotic count, both nurses who participated in the counting documented the accurate count at the change of each shift for three of four medication carts reviewed. Observations revealed that during the narcotic count process, nurses did not consistently sign the accountability pages in the narcotic count binders at shift changes. Specifically, multiple count sheets for the medication carts on 1 South, 1 East, and 2 South B were missing numerous required signatures, with some days showing no signatures at all. The facility policy required two licensed nurses to conduct and document a physical inventory of all controlled substances at each shift change, but this was not followed as evidenced by the missing signatures. Additionally, during the observed narcotic count, nurses did not verbalize the names of the drugs or the residents for whom the medications were prescribed, contrary to facility policy. Instead, only the number of medications on each card was announced. Interviews with nursing staff and facility leadership confirmed that the expected process was not being followed, as both the names of the medications and residents should have been verbalized and the count sheets signed by both nurses at each shift change.