Failure to Complete Narcotic Count Signatures on All Shifts
Penalty
Summary
The facility failed to ensure that narcotic counts were properly initialed by two nurses on all three shifts at the change of shift for all six medication carts reviewed. According to the facility's policy, two nurses are required to count and verify the narcotic count at the start of each shift and sign the Narcotic Count Sheets. However, documentation review revealed multiple instances across all medication carts where either the counting nurse, the recording nurse, or both did not sign off to indicate the narcotic count was correct for various shifts and dates. Direct observations of the medication carts, along with interviews with nursing staff, confirmed that the narcotic count sheets were not consistently signed as required. Each nurse interviewed acknowledged that the sheets should have been signed during each shift change and verified that the required signatures were missing for their respective carts. The Director of Nursing also confirmed that the narcotic sheets were not signed off on each shift as per policy. No specific residents were identified as being directly affected in the report, and there is no mention of any adverse outcomes or medical history related to the residents. The deficiency centers on the facility's failure to follow its own policy for narcotic accountability, as evidenced by incomplete documentation and staff confirmation of the lapses.