Failure to Perform Dual Narcotic Counts and Ensure Medication Availability
Penalty
Summary
Facility staff failed to follow professional standards and facility policy for controlled substance management and medication administration. Review of the facility’s policies showed narcotics were to be physically counted at each shift change by both the incoming and outgoing licensed nurse or CMT, with both staff signing the Shift Verification of Controlled Substance Count form. From 12/08/25 through 12/31/25, multiple shifts lacked the required two staff signatures, and on some shifts there were no signatures at all, indicating that the required dual narcotic counts were not consistently completed or documented. Interviews with an LPN, the administrator, the ADON, and the DON confirmed that staff were required to perform and document narcotic counts at the beginning and end of each shift, and that the DON/ADON were responsible for auditing these forms. They also stated that failure to complete these counts could result in an inability to determine why a narcotic count was incorrect or who might be responsible for missing medication. The facility’s Medication Ordering and Receiving from Pharmacy policy required staff to reorder medications four days in advance of need, and at least seven days in advance for medications requiring special processing, to ensure an adequate supply. The Medication Administration Guidelines policy required that residents receive medications on a timely basis and in accordance with established policies. Despite these policies, surveyors determined that medications were not available as ordered for three sampled residents, and medications were not administered as ordered when unavailable. The report identifies that these failures occurred for three residents out of three sampled, in the context of a facility census of 90.1, but does not provide additional clinical details about the residents’ diagnoses or conditions at the time of the deficiency.
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