Failure to Document Narcotic Counts at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one of three nurse medication carts reviewed. Specifically, LVNs responsible for the 100/200 hall nurse cart did not consistently count and sign for controlled drugs at every shift change, as required. Record review and observation revealed missing signatures for both off-duty and on-duty nurses on the narcotic count sheet for three consecutive shifts. Interviews with the involved LVNs confirmed that although they performed the narcotic counts, they did not sign the count sheets immediately after, citing interruptions and being busy with resident care or new admissions. The DON confirmed that the expectation is for nurses to sign the narcotic count sheet at the beginning and end of each shift after completing the count with the incoming and outgoing nurse. The DON also stated that without these signatures, there is no proof that the counts were performed. Review of the facility's policy on receiving controlled substances did not address the specific concerns identified in this incident.