Incomplete Documentation of Controlled Substance Counts
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards, specifically regarding the documentation of controlled substance inventory counts. Review of the Controlled Substance Inventory Sheets for several units revealed 149 blank signature spaces between 12/1/2025 and 12/19/2025, indicating that the required shift-to-shift counts were not consistently signed off by both the incoming and outgoing nurses. Facility policy and the inventory record form both require that two nurses perform and sign off on the count at each shift change. Multiple staff interviews confirmed that the process was not always followed, with some nurses attributing the missing signatures to distractions, forgetfulness, or staff floating between units. In some cases, nurses working double shifts did not sign between shifts, despite having counted and verified the medications. The Director of Nursing and other supervisory staff acknowledged that the expectation was for both nurses to count and sign for controlled substances at every shift change, regardless of staffing patterns or shift length. The incomplete records were confirmed by several nurses and supervisors during interviews, who emphasized the importance of signatures for accountability and tracking access to narcotics. There was no indication of a staffing shortage contributing to the issue, and the missing signatures were attributed to lapses in following established procedures.