Failure to Document Controlled Substance Shift Change Counts
Penalty
Summary
The facility failed to properly account for controlled substances by not ensuring that the Shift change accountability record was consistently completed. During observations and interviews, it was found that the controlled substance sign-in sheet for one medication cart had missing initials on several dates, indicating that the required signatures from both the incoming and outgoing nurses were not always documented. Licensed Practical Nurses confirmed that while the narcotic count is supposed to be performed and documented at every shift change, there were instances where initials were missing, and it was unclear whether the count had actually been performed on those dates. Further review with the Director of Nursing and the Administrator revealed that they were unaware of the missing initials and expected the narcotic count and sign-in process to be completed every shift. When asked to provide documentation, copies of the sign-in sheets were produced with all dates filled in, despite earlier observations of missing initials. The facility's policy requires that both nurses count and sign for controlled substances at each shift change, but this procedure was not consistently followed as evidenced by the incomplete records.