Failure to Ensure Accurate Narcotic Count and Documentation
Penalty
Summary
The facility failed to ensure proper safeguards and systems for the accurate reconciliation and accounting of controlled substances on one of three medication carts. During an observation of a medication cart with an LPN, surveyors reviewed narcotic count reconciliation sheets and shift change sign-off sheets for several months. Multiple entries were found to be missing one or both required nurse signatures, with some days having no entries at all. The facility was unable to provide all requested medication cart logs, submitting only the shift change sign-off sheets. Interviews with nursing staff and the DON confirmed that the established procedure requires two nurses to count and sign for controlled substances at each shift change, but this was not consistently followed as evidenced by the missing signatures and incomplete documentation. The facility's policy requires that both the nurse receiving and the person delivering controlled substances count and sign together, and that the consultant pharmacist routinely monitors these records. Despite this, the review of documentation revealed repeated failures to obtain the necessary signatures and maintain complete records for controlled substances over multiple weeks. Staff interviews acknowledged that these omissions did not meet facility expectations and that the dual-nurse count is intended to ensure accuracy and accountability for narcotic medications.