Failure to Complete Shift-to-Shift Narcotic Reconciliation for Multiple Medication Carts
Penalty
Summary
The facility failed to ensure that shift-to-shift narcotic reconciliation was completed for three of four medication carts reviewed, specifically on the A Unit, Cottage Unit, and C Unit medication carts. During medication storage observations, it was found that required signatures and counts were missing from the Shift To Shift Narcotic Count records at the beginning of shifts. For example, an LPN did not sign or record her count when taking over the cart, and discrepancies in the number of controlled medication cards and sheets were not recognized or reported as required. Review of records revealed multiple instances in May and June where shift-to-shift reconciliation was not documented for these carts. Interviews with nursing staff confirmed that both the incoming and outgoing staff were required to count and verify controlled substances together, document the count, and sign the records. However, staff admitted to not completing these steps consistently, and in some cases, discrepancies in the controlled substance counts were not reported to the DON as required by facility policy. The DON confirmed that incomplete reconciliation records made it impossible to verify if the process had been completed and that any discrepancies should have been immediately reported and investigated. The facility's current policy required strict compliance with laws and regulations regarding the handling, storage, and documentation of controlled substances, including shift-to-shift inventory reconciliation and immediate reporting of discrepancies. Despite this, the observed and documented lapses in reconciliation and documentation created opportunities for unrecognized discrepancies in controlled medication counts, affecting a significant number of residents who received controlled medications from the affected medication carts.