F0755

D

Failure to Maintain Two-Nurse Narcotic Count Verification Between Shifts

Laplata, Maryland Survey Completed on 01-09-2026

Penalty

Fine: $17,215

Summary

Facility staff failed to ensure that end-of-shift narcotic count verifications were consistently completed and signed by two nurses for one of two medication carts on the A wing. Review of the A wing narcotic logbooks on 1/7/26, prompted by a prior facility report from August 2025 regarding alleged improper wasting of narcotics by a former unit manager without a witness, showed multiple days between August 2025 and December 2025 where two-nurse verification at shift change was not documented. The A unit manager stated that two nurses are supposed to sign each shift and that staff working a double shift are to complete the narcotic count with the shift supervisor. She was informed of multiple gaps in the narcotic log, and copies of the logs from August through December were requested.

The DON reported that her practice was to instruct staff working a double shift to sign their initials for both shifts, which she suggested could explain missing signatures. However, comparison of staff schedules for selected time frames with the narcotic logs and corresponding signatures, conducted with the DON on 1/8/26, revealed that staff still failed to consistently sign the narcotic log between shifts even when working double shifts. Review of the facility’s Controlled Substance Administration and Accountability policy, last revised 3/2023, showed that the controlled drug record is intended to document both narcotic disposition and patient administration, and that the charge nurse or designee is to conduct a daily visual audit of controlled substance documentation with spot checks for proper destruction documentation and physician orders for removed medications. Despite these policy requirements, the narcotic log shift-to-shift verification process was not maintained, as noted throughout the survey and again at exit on 1/9/26.