Failure to Complete and Document Shift Narcotic Counts with Two Staff Members
Penalty
Summary
Facility staff failed to complete shift-to-shift controlled drug counts with two staff members as required by facility policy, resulting in incomplete documentation and discrepancies in controlled medication counts. The facility's policy directs that a physical inventory of narcotics be completed at each shift change by one outgoing and one incoming RN, LPN, or CMT, with both staff members verifying and signing the count. However, review of the Controlled Substance Shift Change Forms revealed that on multiple occasions, only one staff signature was present, and in some instances, there were missing signatures for entire shifts. This failure to follow policy was confirmed through interviews with staff, who acknowledged that narcotic counts were sometimes not performed with two people and that documentation was incomplete or missing due to busy shifts or staff forgetting to sign the forms. A specific incident involved a resident who was moderately cognitively impaired and received opioid pain medication. The controlled substance log for this resident's Tramadol prescription did not contain documentation that staff counted the medication between certain dates. A review showed a discrepancy in the pill count, with two pills unaccounted for over a three-day period. Staff interviews indicated that the missing medication was discovered when a count was eventually performed, and it was reported to a nurse. Staff involved denied taking the medication and stated that they had received education on the correct procedure for counting and documenting narcotics. Further interviews with nursing and administrative staff confirmed that the expectation was for narcotics to be counted at the beginning and end of each shift by two staff members, with documentation on the appropriate forms. However, it was acknowledged that this process was not consistently followed, and audits of the forms were not being performed regularly at the time of the incident. The deficiency was identified through observation, record review, and staff interviews, which collectively demonstrated a pattern of non-compliance with the facility's narcotic count policy.