Failure to Perform Two-Nurse Narcotic Shift Count and Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to ensure that the required shift count of controlled substances was conducted by two licensed nurses during the handoff of narcotic keys, and did not maintain complete, accurate, and unaltered documentation on the Controlled Drug Inventory Sheets. On the date in question, a charge nurse discovered that both a blister pack of oxycodone 5 mg and its corresponding disposition record sheet were missing from the medication cart and narcotic count book. Despite searching the medication cart and room, the missing medication and documentation could not be located. The incident was reported, and statements were obtained from all staff with access to the medication cart. Interviews revealed that an agency LPN, who was scheduled for the day shift, arrived late and did not perform the required narcotic count with the outgoing nurse. Instead, the narcotic keys were handed over without a count, contrary to facility policy. Later, another LPN reported being rushed during the shift change and did not count the total number of disposition sheets or physical blister cards as required. The Controlled Medication Shift Change Log showed alterations, with numbers crossed off and changed, and missing disposition sheets for the relevant period. Staff interviews confirmed that the required two-nurse count was not performed at multiple shift changes, and documentation was altered or incomplete. Facility policy requires a complete count of all controlled substances at each shift change, performed by two licensed nurses, and mandates accurate recordkeeping. The investigation found that these procedures were not followed, resulting in missing medication, altered documentation, and a lack of reconciliation between narcotic cards and disposition sheets. The failure to adhere to these protocols led to the deficiency cited in the report.