Failure to Maintain Accurate Narcotic Count Documentation at Shift Changes
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, the facility did not establish or maintain a system of record for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation at each shift change. Record reviews revealed missing documentation on the Change of Shift Narcotic Count Sheets for multiple halls and shifts, with several instances where both on-coming and off-going staff did not sign or complete the required narcotic counts. Interviews with certified medication aides (CMAs) and the Assistant Director of Nursing (ADON) confirmed that it was the facility's expectation for both off-going and on-coming staff to count narcotic medications and sign the count sheets at each shift change. The Regional Director of Clinical Services acknowledged that the narcotic count process was not consistently included in new employee orientation. Review of the facility's contracted pharmacy policy indicated that a system must be in place to record the receipt, usage, and disposition of all controlled substances in sufficient detail for accurate reconciliation, which was not followed as evidenced by the missing documentation.