F0755

D

Failure to Properly Document Controlled Substance Counts on Medication Carts

Idaho Falls, Idaho Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure controlled medications were consistently tracked and secured in accordance with its own policy and procedures. The facility’s “Inventory Control of Controlled Substances” policy, revised 08/01/24, required incoming and outgoing nurses to count all Schedule II controlled substances and other medications with a risk of abuse or diversion at each shift change and document the results on a Controlled Substance Count Verification/Shift Change Sheet. The policy also required staff to count all Schedule III–IV controlled substances in accordance with facility policy and applicable law. During a medication cart audit on Hall 2 on 3/18/26 at 8:17 AM, surveyors observed Narcotic Card Item Count sheets dated 1/1/26 to 1/15/26, 2/1/26 to 2/15/26, and 3/1/26 to 3/15/26 that were missing one of the required licensed nurse signatures on 1/1/26, 2/3/26, 2/10/26, 2/11/26, and 3/10/26.

During a medication cart audit on Hall 4 on 3/18/26 at 8:50 AM, surveyors observed a Narcotic Card Item Count sheet dated 3/11/26 to 3/21/26 that was missing one licensed nurse signature on 3/12/26. An LPN interviewed at 8:19 AM stated that two nurses should have signed the Narcotic Card Item Count sheet and had not. Another LPN interviewed at 8:55 AM similarly stated that two nurses should have signed the Narcotic Card Item Count sheet when they accepted or released the medication cart. At 10:16 AM, the DON confirmed that two nurses were expected to sign the Narcotic Card Item Count sheet when accepting or releasing the medication cart and acknowledged that this had not occurred. These findings were true for 2 of 2 medication carts reviewed and affected all residents receiving controlled medications in the facility.