Failure to Maintain Proper Narcotic Accountability on Medication Carts
Penalty
Summary
Surveyors determined the facility failed to ensure controlled medications were properly tracked and secured from potential theft or diversion on two of three medication carts reviewed. During an audit of the 200 Hall medication cart on 1/7/26 at 4:40 PM, the narcotic accountability sheet for 1/1/26 to 1/7/26 was observed with one required licensed nurse signature missing. Shortly thereafter, a CMA stated that two nurses should have signed the narcotic accountability sheet and acknowledged she had not signed it when she accepted the medication cart that day. During an audit of the 100 Hall medication cart at 4:45 PM, the narcotic accountability sheet for the same date range was also found with one licensed nurse signature not documented. An LPN stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart. The DON likewise stated that two nurses should have signed the narcotic accountability record when they accepted or released the medication cart. These observations and staff interviews showed that required dual signatures for narcotic accountability were not consistently obtained or documented for controlled medications on two medication carts, creating the potential for undetected misuse or diversion of controlled medications for all residents receiving such medications in the facility.
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