Missing Nurse Signatures on Narcotic Count Logs
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled, as required by policy. Specifically, over a 104-day period, there were 37 instances where nurse signatures were missing from the change of shift narcotic count log out of 624 opportunities. The facility's policy mandates that a complete count of all narcotics must occur at every change of personnel, with both the outgoing and incoming nurses signing the narcotic count sheet to indicate agreement with the count and transfer of responsibility. Review of narcotic count sheets revealed missing signatures, indicating that the narcotic count was not always completed before the transfer of narcotic keys. Observations and interviews confirmed that the count process was generally followed, with nurses stating that the count was performed between shifts and that they could not leave until it was completed. However, the missing signatures were attributed to nurses forgetting, being rushed, or needing to return to the floor quickly. Despite the absence of medication count discrepancies, the lack of signatures meant there was no documented proof that reconciliation and transfer of responsibility had occurred as required by policy.