F0867

E

QAPI Committee Failed to Sustain Corrective Actions for Narcotic Documentation

Lakeland, Florida Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure its Quality Assurance and Performance Improvement (QAPI) Committee effectively implemented and monitored corrective actions to prevent recurrence of previously identified problems with controlled medication documentation. The facility had been cited earlier under F755 for issues related to narcotic management and had developed a Plan of Correction with specific education and auditing processes. Education on narcotic shift-to-shift documentation, including requirements for count sheets, comment sections, signatures at the time of count, and counts when medications are received from the pharmacy, was initiated for nursing staff. Audit tools were also created with the stated goal of ensuring compliance with proper documentation on narcotic shift count sheets, and audit results showed 100% compliance on paper.

Despite these measures, direct observations and record reviews showed that the corrective actions were not consistently carried out in practice. Review of Controlled Medication Inventory Sheets (CMIS) on multiple medication carts revealed incomplete and inaccurate documentation of narcotic counts over several days. On one cart, incomplete documentation of narcotic counts was found, and the RN present acknowledged that someone had forgotten to write down the name of the medication. On another cart, incomplete documentation was also identified, and the LPN stated there was no need to complete the resident’s name on the CMIS, indicating a misunderstanding or disregard of documentation requirements.

Further review of additional carts showed similar issues. On one cart, an RN reported not having received recent education about narcotic management, despite the facility’s claim that all nurses had been educated. On another cart, the CMIS documented a total of 23 narcotic cards, while only 22 cards were physically present, and the RN Unit Manager acknowledged that the resident’s name should be documented and later reported that staff had told her they forgot to document the removal of one narcotic card. Another LPN described the expected process for narcotic counts and documentation, including documenting when medication cards are received or removed and ensuring all entries are complete and accurate, but the documented deficiencies showed that this process was not consistently followed. These findings, combined with QAPI meeting records that focused on reviewing the CMS Form 2567 and discussing corrective actions, demonstrate that the QAPI Committee did not effectively ensure that the planned corrective actions for narcotic documentation were fully implemented and sustained.

The facility’s own QAPI policy describes a comprehensive, data-driven program intended to involve all departments and staff, focus on systems and processes, and use root cause analysis and performance improvement projects to achieve sustained improvement. It states that the Administrator is responsible for the Quality Assessment and Assurance Committee, which is to meet at least monthly, obtain data from multiple sources, and monitor and evaluate changes. However, the continued presence of incomplete and inaccurate narcotic documentation on multiple medication carts after the prior citation and Plan of Correction shows that the systems and monitoring described in the policy were not effectively applied to this issue. The deficiency centers on the gap between the facility’s written QAPI framework and the actual implementation and oversight of narcotic documentation practices on the units.