Failure to Consistently Document Controlled Substance Counts at Shift Change
Penalty
Summary
Nursing staff failed to consistently follow established procedures for verifying and documenting the count of controlled substances at shift change on two medication carts. Facility policy requires that both the oncoming and outgoing nurses count controlled medications together at the end of each shift, document the count, and report any discrepancies to the director of nursing services. However, a review of narcotic count records revealed multiple instances where the oncoming nurse did not sign off to confirm the count was completed and correct on both the green and lilac nursing unit medication carts. Specifically, on several dates, the required signatures were missing from the narcotic count sheets for both day and night shifts. Staff interviews confirmed that it is the expectation for nursing staff to review and sign off on narcotic count sheets at each shift change. The nursing home administrator acknowledged that the facility did not consistently implement procedures to ensure accurate controlled drug records, as required by facility policy and state regulations.