Failure to Accurately Document Controlled Medication Counts at Shift Change
Penalty
Summary
The facility failed to ensure accurate documentation of controlled (Schedule II) medications by both oncoming and off-going nurses during shift changes for two medication carts. According to facility policy, Schedule II controlled medications must be jointly counted and documented by both nurses at each shift change. However, a review of the narcotic logbooks for the First Floor [NAME] Hall and First Floor East Hall medication carts revealed multiple instances where required signatures were missing from the narcotic count sheets. Specific omissions included missing signatures from either or both nurses on several dates and shifts, as confirmed by staff interviews. Interviews with LPNs and the Nursing Home Administrator confirmed that the narcotic sheets were not consistently signed as required. The facility's expectation is for staff to follow procedures that promote accurate controlled drug records, but the documentation reviewed showed repeated failures to comply with these procedures. The cited deficiencies are in violation of state regulations regarding nursing service, pharmacy services, and clinical records.