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F0755
D

Failure to Consistently Sign Narcotic Record Books by Nursing Staff

Chestertown, Maryland Survey Completed on 08-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that narcotic record books were consistently signed by both incoming and outgoing nurses, as required by facility protocol. During a medication administration observation, surveyors found multiple missing signatures in the narcotic record books, with omissions dating back several months and including recent weekend shifts. Staff confirmed that the protocol required both nurses to sign the narcotic record book at each shift change, but acknowledged that this was not consistently done. In one instance, an LPN admitted to counting narcotics with the outgoing nurse but failed to sign the record book until prompted by the surveyor. Further review of employee files revealed that at least one RN had a history of corrective action notices related to failure to perform narcotic count sign-off with the off-going nurse, with documentation of repeated incidents before and after a specific date. The Director of Nursing confirmed awareness of the issue and reiterated the facility's expectation for both nurses to sign the narcotic record book to ensure accountability and prevent discrepancies.

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