Failure to Consistently Complete Dual-Nurse Narcotic Count Verification
Penalty
Summary
Surveyors found that the facility did not consistently ensure proper reconciliation of narcotic medications in accordance with its Controlled Substance Shift to Shift Count Policy, which required all narcotic medications to be counted and verified by two nurses at each shift-to-shift handoff, with both nurses signing the count sheet. Review of narcotic Controlled Substance Count Sheets for multiple medication stations over a period from early February to late March showed missing second nursing signatures on several dates, indicating that the required dual-nurse verification was not documented. Specifically, Station #1’s count sheet lacked a second nurse signature on one date, Station #2’s count sheet lacked a second nurse signature on three dates, and Station #4’s count sheet lacked a second nurse signature on three dates. This deficiency had the potential to affect 17 residents who received narcotic medications from the facility. During an interview, the Administrator confirmed these findings. No additional resident-specific medical histories or conditions related to this deficiency were described in the report.
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