Failure to Document Controlled Substance Counts at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for two medication carts (Hall 200 and Hall 300) out of four reviewed. Specifically, the responsible RNs did not consistently count controlled drugs at every change of shift and did not sign the narcotic sheet form after the count, as required by facility policy. Record reviews revealed multiple dates with missing signatures for both off-duty and on-duty nurses on the narcotic count sheets for both medication carts. Interviews with the involved RNs confirmed that the counts were performed but the required signatures were omitted, either due to being busy or misunderstanding the policy. One RN was new and had only recently received in-service training on the correct procedure. The DON confirmed that the expectation is for both incoming and outgoing nurses to sign the narcotic count sheet immediately after counting, and acknowledged that missing signatures prevent verification that counts were completed as required. The facility's policy mandates that both staff members sign the controlled substance shift change sheet to verify the accuracy of the medication counts at each shift change.