F0755

E

Inaccurate and Incomplete Documentation of Controlled Substance Counts on Multiple Medication Carts

Lakeland, Florida Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate and consistent documentation of controlled substances on shift-to-shift narcotic count sheets for multiple medication carts. Surveyors observed that the narcotic count sheet for cart 200-A had no entry for the current morning’s count, even though the assigned LPN stated the count itself was correct and that she had simply forgotten to record the total number of narcotic cards. During interviews, nursing staff described the facility’s process: at each shift change, the off‑going and oncoming nurses are required to count narcotic cards together, verify each resident’s narcotic medications, and both sign the Shift-to-Shift Controlled Medication Count. Staff also reported that discontinued or discharged narcotic cards remain in the locked narcotic box in the cart until the DON removes them with another nurse as witness.

Further review of the narcotic binders for carts 100/A, 100/B, and 200/A revealed numerous discrepancies and incomplete or illegible entries. For cart 100/B, surveyors noted multiple instances where the total number of narcotic cards changed between shifts without any explanatory comments, as well as sequences of plus and minus entries that did not mathematically match the documented totals. Some entries showed beginning counts that did not align with the prior shift’s ending count, and there were illegible notations and unclear corrections. Similar issues were found in the 100/A narcotic ledger, including unexplained changes in total card counts, incorrect totals after documented additions and removals, missing shift counts, and entries written in the comments section instead of the total column. In several cases, the total number of cards increased or decreased without any corresponding explanation in the comment section.

The 200/A narcotic count sheets also contained multiple inconsistencies. Surveyors identified shifts where the total narcotic card count decreased or increased from one shift to the next with no documentation in the comment section to explain the change, as well as a missing total entry for an entire shift. There were instances where a new count sheet was started without carrying over the prior total, resulting in a new starting count that did not match the previous ending count. Some entries contained illegible numbers and scratched-out totals before a final number was recorded. During interviews, the ADON and unit manager acknowledged that there were areas for improvement and inaccuracies in the ledgers, and one RN reported that when he left his cart keys with another nurse during a break, he did not document the narcotic count upon his return because the binder was in the ADON’s office. The facility’s own policies require that controlled substances be inventoried at each shift change by both incoming and outgoing nurses, that keys remain in the possession of a licensed nurse, and that all alleged misappropriation be reported, but the observed documentation practices and omissions did not consistently follow these requirements.

Interviews with leadership and pharmacy personnel further clarified the existing processes and expectations but also underscored the documentation gaps. The ADON stated that when pharmacy delivers narcotics, the receiving nurse verifies the prescription with the delivery person, signs the delivery documentation, places the prescription in the narcotic book with a witness, and adjusts the shift-to-shift count. The ADON also stated that if a nurse relinquishes keys to another nurse for a break, the expectation is that narcotics are counted before and after the break, yet the RN who handed off his keys did not document a count upon return. Staff referenced at least one prior incident of a missing narcotic pill that was reportedly resolved, but the ADON indicated she had not had concerns about narcotic diversion during her tenure and believed pharmacy would alert the facility if there were issues. The consultant pharmacist reported that their role includes monthly medication review, checking for expiration dates, and verifying destruction of medications, but not checking narcotic counts beyond destruction processes. These combined observations and interviews demonstrate that the facility did not consistently maintain accurate, complete, and legible controlled substance count records as required by its own policies and regulatory expectations.

The facility’s written policy on Schedule II controlled substances requires that when a controlled medication is administered, the nurse must document on the declining inventory sheet the date, quantity administered, amount remaining, and initials, and that an inventory count of all controlled medications on each unit be performed at each shift change by both incoming and outgoing nurses, with both signing the inventory form. The policy on abuse, neglect, exploitation, and misappropriation states that the facility will maintain an inventory of residents’ property and report alleged misappropriation in accordance with federal and state law. Despite these written requirements, the survey findings show repeated failures to document shift-to-shift narcotic counts accurately, to reconcile changes in total card counts, and to ensure that all required entries and signatures were present on the narcotic ledgers for multiple carts over an extended period.