F0761

E

Failure to Consistently Document Dual Nurse Signatures for Narcotic Counts

Silver Spring, Maryland Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to consistently document controlled substance counts with the required dual nurse signatures during shift-to-shift narcotic counts on two of three units. On the Choice unit, during a medication pass observation with an LPN, review of the narcotic control book showed a missing incoming nurse signature for the 3:00 PM to 11:00 PM shift and a missing outgoing nurse signature for the 11:00 PM to 7:00 AM shift on a specific date. The assisting nurse from another unit who helped complete the narcotic count during a family emergency for the scheduled incoming nurse did not sign the narcotic book, despite the expectation that both outgoing and incoming nurses sign after jointly counting narcotics.

On the Independence unit, during another medication pass observation with an LPN, review of the narcotic binder revealed three missing signatures: an incoming nurse signature for the 3:00 PM to 11:00 PM shift, an outgoing nurse signature for the 11:00 PM to 7:00 AM shift on the same date, and an incoming nurse signature for the 11:00 PM to 7:00 AM shift on a different date. The LPN on that unit confirmed the missing signatures and stated that both outgoing and incoming nurses are required to sign to verify that narcotics were counted. The DON also confirmed that facility expectations require two nurse signatures after a joint count to document that all controlled medications are accounted for, and acknowledged the missing signatures when informed of the findings.