Failure to Complete Shift-to-Shift Narcotic Reconciliation and Documentation
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliations were consistently completed to account for controlled medications on two of five medication carts reviewed. During medication storage observations, it was found that the Narcotic Count Log for one unit lacked a count and off-going staff signature when a registered nurse took over the cart at the beginning of his shift. The nurse confirmed that the shift-to-shift count was not completed because the off-going nurse left before the count was done, and review of the Narcotic Count Log revealed multiple dates missing required counts and signatures. Additionally, two controlled medications in the narcotic drawer did not have corresponding Controlled Substances Record sheets in the narcotic binder, and the nurse had not identified or reported these discrepancies due to the lack of reconciliation at the shift change. Review of records showed that shift-to-shift reconciliation was missing for 37 out of 50 opportunities on this cart. The residents involved had diagnoses including Parkinson's disease, anxiety, osteoarthritis, and spinal stenosis, and were prescribed controlled medications such as morphine sulfate and tramadol. On another medication cart, the Narcotic Count Log was missing beginning and ending card count numbers for a specific date. Staff interviews confirmed that both the outgoing and incoming nurses were required to count and sign for narcotics at each shift change, but review of records showed that shift-to-shift reconciliation was missing for 4 out of 45 opportunities. The facility's policy required all controlled substances to be counted and documented at each change of hands of the narcotic cart keys, with both staff members participating in the count and recording the results. Despite this policy, the required documentation and reconciliation were not consistently completed, as evidenced by the missing counts and signatures.