Failure to Document Controlled Substance Count at Shift Change
Penalty
Summary
The facility failed to ensure that the outgoing nurse signed the Controlled Substances Check Form for the First Floor Team II medication cart, specifically missing a signature for the 3-11 shift on 7/11/2025. This omission was identified during a medication storage and labeling review with an LPN, who confirmed that nurses are required to sign the form to document that controlled medications have been counted and accounted for at each shift change. The Director of Nursing also stated that both incoming and outgoing nurses are expected to count and sign for controlled substances during shift changes to ensure none are missing. This deficiency affected four residents who were prescribed controlled medications, including morphine sulfate, hydrocodone-acetaminophen, and lorazepam, for conditions such as chronic pain syndrome, anxiety disorder, and depression. Facility policy and the registered nurse job description both require accurate narcotic records and dual signatures for controlled substance counts at each shift change, but this procedure was not followed as documented by the missing signature.