Failure to Maintain Complete Dual-Nurse Narcotic Reconciliation Logs
Penalty
Summary
The facility failed to ensure accurate reconciliation and accounting of controlled substances on two of three sampled medication carts. During review of the narcotic reconciliation log for the 100 medication cart, surveyors and an LPN identified missing nurse signature entries on six shifts within a specified date range, despite the expectation that these entries not be left blank. A similar review of the 300 medication cart narcotic reconciliation log revealed missing nurse signature entries on five shifts in the same period. The facility’s policy, revised in June 2025, instructed staff to reconcile controlled medications every shift by both incoming and outgoing licensed nurses at change of shift, but the documentation did not show that this process was consistently followed. Interviews with nursing staff and leadership confirmed that two nurses are required to complete the narcotic count and reconciliation log at each shift change to ensure accountability and verify that residents receive required medications. An LPN stated that there should be no missing signature entries for the dates in question because, without signatures, it cannot be proven that two nurses performed the narcotic counts for those shifts. The ADON and DON acknowledged that the narcotic reconciliation logs contained missing entries that did not meet facility expectations and that the logs with these deficiencies were provided to the survey team. The deficient practice was identified through observations, interviews, and review of facility documentation and policy.
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