F0755

E

Failure to Consistently Reconcile and Document Controlled Drug Counts Between Shifts

Topeka, Kansas Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to ensure accurate reconciliation of controlled drugs at the end of daily work shifts. The facility had a census of 54 residents and a sample of 14 residents, with four medication carts and two medication rooms reviewed. On review of the Narcotic Shift Count Sheet for the west hall covering an 88‑day period from 01/01/26 to 03/29/26, surveyors found that on 59 of those days there was a missing signature from either the on‑coming nurse or the off‑going nurse, indicating that the required shift‑to‑shift narcotic count reconciliation was not consistently completed. Specific dates with missing signatures included multiple days in January, February, and March. An administrative nurse confirmed that facility policy and expectations required the narcotic count to be reconciled between shift changes daily and every shift, and the written Pharmacy Services Overview policy stated the facility would accurately and safely provide pharmaceutical services, including medications and the services of a licensed consultant pharmacist.

These observations and record reviews demonstrated that the facility did not consistently follow its own policy and expectations for controlled drug reconciliation, as evidenced by the frequent absence of required nursing signatures on narcotic shift count sheets over the reviewed period.