Failure to Accurately Document Narcotic Counts During Shift Change
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the accurate reconciliation of controlled substances for one of two medication carts reviewed. On 07/27/2025, LVN E did not sign the narcotic sign on and sign off sheet when assuming and handing off the medication cart, as required by facility policy. Record review showed missing signatures for both the start and end of LVN E's shift. Interviews with LVN D and LVN E confirmed that both nurses were responsible for counting the narcotics together and signing the log at each shift change, but this procedure was not followed on the specified date. The Director of Nursing (DON) also confirmed that both nurses are required to sign the log and that the logs are to be verified weekly by the DON or ADON. The facility's policy on controlled substances requires that controlled medications be counted upon delivery and at each shift change, with both the outgoing and incoming nurses signing the designated record. The failure to document the narcotic count as required was observed during a review of the medication cart's records and confirmed through staff interviews. This lapse in procedure could result in unaccounted medications, as noted by the staff during interviews, and was identified as a deficiency in the facility's pharmaceutical services.