Failure to Accurately Document Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to provide a consistent and accurate account of controlled medications by not ensuring staff completed documentation of narcotic counts at each shift change. Record reviews revealed multiple blank entries on Narcotic Release Forms for several medication carts across various dates, indicating that staff did not always document the required shift-to-shift narcotic counts. Interviews with licensed nurses and the Director of Nursing confirmed that the forms were incomplete and should have been filled out according to facility policy, which requires two licensed nurses to conduct and document a physical inventory of all controlled medications at each shift change. One resident involved had significant medical needs, including a feeding tube, severe cognitive impairment, and dependence on staff for daily activities. The incomplete documentation of controlled medication counts meant there was no way to ensure that narcotics were properly accounted for or administered safely and accurately to residents. The Director of Nursing acknowledged that the lack of complete and accurate forms could result in discrepancies in the amount of narcotics available for residents and potentially delay treatments.