Failure to Maintain Dual Nurse Signatures on Narcotic Accountability Sheets
Penalty
Summary
Surveyors found that the facility failed to properly track and secure controlled medications by not completing required dual nurse signatures on narcotic accountability sheets for two medication carts. On the 400 Hall medication cart audit conducted on 3/3/26 at 8:52 AM, the narcotic accountability sheet dated 3/2/26 to 3/3/26 was missing one licensed nurse signature for 3/3/26, and the RN interviewed confirmed that two nurses should have signed the sheet. On 3/4/26 at 8:44 AM, during the 100 Hall medication cart audit, narcotic accountability sheets dated 2/6/26 to 2/12/26, 2/13/26 to 2/20/26, and 3/1/26 to 3/3/26 were found to be missing one licensed nurse signature on multiple dates (2/11/26, 2/12/26, 2/13/26, 2/19/26, and 3/3/26). An RN and the CNO both stated that two nurses were required to sign the narcotic accountability sheets when accepting or releasing the medication cart, but this had not occurred as required, creating the potential for undetected misuse and/or diversion of controlled medications for all residents receiving these medications. No specific residents, medical histories, or clinical conditions were identified in the report; the deficiency pertained to the facility’s medication accountability process for controlled substances affecting all residents who received controlled medications.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.