Failure to Complete Shift-to-Shift Controlled Substance Counts by Two Licensed Nurses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that two licensed nurses conducted and documented a shift-to-shift physical inventory of controlled substances for all medication carts as required by facility policy. Surveyors reviewed the controlled substance shift-to-shift count forms for the second-floor and third-floor medication carts for September 2025 and found missing initials in the “Nurse Off” boxes at specific morning shift-change times. On the second-floor [NAME] medication cart, the “Nurse Off” initial box was left blank for a morning shift change on September 17, 2025. On the third-floor medication cart, the “Nurse Off” initial box was left blank for a morning shift change on September 23, 2025. These documentation gaps occurred for carts that contained controlled substances prescribed for 7 residents on the 3J cart and 5 residents on the 2J cart. During interviews, an LPN stated that every nurse is responsible for ensuring the narcotic count is correct and that two nurses are to count the controlled substances in the medication cart and sign the “on” and “off” spaces on the shift-to-shift count sheet, and that nurses are to notify the DON if initials are missing. An RN explained that the controlled substance shift-to-shift count sheets are used to document that the total number of narcotics in the cart is correct at the end of each shift, and that the incoming and outgoing nurses count all narcotics together and both initial the form once they agree the count is correct, notifying the DON if there is any discrepancy. The MDS Coordinator confirmed that nurses are responsible for completing these sheets to verify that all narcotics in the cart are accounted for and that the DON should be notified if the sheets are not initialed and completed for each shift. Review of the facility’s July 2025 policy on Controlled Substance Administration & Accountability documented that two licensed nurses must account for all controlled substances and access keys at the end of each shift, which was not consistently followed as evidenced by the missing “Nurse Off” initials.
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