Failure to Ensure Accurate Narcotic Reconciliation and Documentation
Penalty
Summary
The facility failed to maintain proper safeguards and systems for the accurate reconciliation and accounting of controlled substances. During an observation of Medication Cart #1's narcotic logbook, surveyors identified several discrepancies in the Shift to Shift Narcotic Sheet & Card Verification for a period in May. These included count inconsistencies over multiple days, six missed staff signature entries, duplicate signature entries, and an incorrect year written on the log sheet. Interviews with the DON, clinical resource staff, and an RN confirmed that the facility's expectation is for two licensed nurses to sign off on narcotic counts at each shift change, and that the missing or duplicate signatures did not meet facility standards. Facility policy requires the DON to supervise all personnel administering medications and mandates that medication-related issues be reviewed as part of the quality assurance and performance improvement process. Despite these policies, the observed documentation failures and inconsistencies in narcotic counts indicate that the required procedures were not consistently followed, leading to a deficiency in the facility's pharmaceutical services.