Failure to Accurately Reconcile and Document Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to ensure that drug records were in order and that all controlled medications were accurately reconciled at the start and end of each shift for two medication carts. Record reviews revealed multiple instances of missing documentation on the Change of Shift Narcotic Count Sheets for both carts, with specific dates and shifts lacking required signatures and counts. This failure was confirmed through interviews with staff, including a Certified Medication Aide (CMA), a Licensed Vocational Nurse (LVN), and the Assistant Director of Nursing (ADON), all of whom acknowledged the expectation that both off-going and on-coming staff count and sign for narcotics at each shift change. The facility's policy requires nursing staff to count controlled drugs at the end of each shift, with both the nurse coming on duty and the nurse going off duty participating in the count and documenting any discrepancies. Despite this policy, the audit process conducted by the ADON identified deficiencies in narcotic count documentation, and staff interviews confirmed the established procedures were not consistently followed. The administrator also acknowledged the expectation for shift-to-shift narcotic counts and the potential for negative outcomes if the process is not adhered to.