Failure to Maintain Dual-Nurse Narcotic Accountability on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications on one of two medication carts reviewed. During an audit of the North Hall medication cart, narcotic accountability sheets dated from 1/1/26 to 1/27/26 were observed with only one licensed nurse signature documented for 1/21/26, instead of the required two signatures. An LPN stated that two nurses should have signed the narcotic accountability sheet when they accepted or released the medication cart, and the DON confirmed that two nurses were expected to sign the narcotic accountability sheet at those times. This deficiency involved the process for documenting controlled medication accountability rather than a specific resident, and it affected all residents who received controlled medications in the facility, as the lack of dual signatures meant controlled medications on that cart were not properly tracked for that date.
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