F0755

E

Lack of Documented Shift Counts for PRN Controlled Medications

Springfield, Missouri Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

Failure to maintain an effective system for reconciliation of controlled substances occurred when nursing staff did not document shift-to-shift narcotic counts for two medication carts, identified as Skilled 1 and Skilled 2, which contained all PRN controlled medications for residents. Surveyor review of the controlled medication books on each cart showed there were no signature sheets for nurses to sign when counting controlled medications at the beginning and end of each shift. Observation showed the two medication carts were located inside the locked nurse station and contained PRN controlled medications for the facility’s 106 residents.

During interviews, two LPNs stated that at the beginning and end of each shift, the off-going and oncoming nurses counted the quantity of each controlled medication and the total number of controlled medication packages on their assigned carts, but they did not sign to confirm the shift count. Both LPNs reported they had worked at the facility for several months and had never signed to confirm beginning and end of shift counts. The DON stated that nurses were expected to count all controlled medications and sign a signature sheet each shift to confirm the count was correct, but acknowledged being unaware that nurses were not signing and that audits were not being done to ensure compliance. The Administrator also stated that nurses should be signing for completion and accuracy of the narcotic count at the beginning and end of each shift.