Failure to Consistently Verify and Document Narcotic Counts at Shift Change
Penalty
Summary
The facility failed to ensure that narcotic counts were consistently verified and documented by both the off-going and oncoming nurses for all three medication carts reviewed. According to the facility's policy, two licensed nurses are required to conduct and document a reconciliation or physical inventory of all controlled medications at each shift change. However, review of the narcotic count sheets revealed missing signatures in the designated spaces for both off-going and oncoming nurses on multiple occasions. Specifically, the C-Hallway and Special Care Unit medication carts had blank signature spaces for the oncoming nurse, while the A-Hallway cart had a blank space for the off-going nurse, with staff confirming that signatures were omitted due to forgetfulness or signing in the wrong spot. Staff interviews confirmed that the required documentation was not completed as per policy, with nurses acknowledging that they forgot to sign the narcotic count logs after performing the counts. The Director of Nursing stated that the expectation is for both the off-going and oncoming nurses to perform the narcotic count and sign the log at each shift change. These lapses in documentation were observed and verified during the survey process.