Failure to Perform and Document Required Shift Counts for Controlled Substances
Penalty
Summary
The facility failed to maintain accurate reconciliation records for controlled substances on all six medication carts on two units that did not use automated dispensing systems. Facility policy on Controlled Substance Administration and Accountability, last reviewed February 26, 2026, required two licensed nurses to account for all controlled substances at the end of each shift and to sign the shift count log for each cart. Review of controlled substance logs for January, February, and March 2026 for Unit I Carts 1, 2, 3 and Unit II Carts 1, 2, 3 showed that there was no documented evidence that controlled substances were counted after every shift on 15 of 31 days in January, 14 of 28 days in February, and 11 of 24 days in March. In interviews, the Director of Nursing confirmed that the oncoming and offgoing nurses were required to sign the specific cart’s Shift Count Log to verify the narcotic count and that there were no discrepancies, and also confirmed that there was no evidence that the controlled substances were counted and signed off on the identified dates as required by facility policy. No specific residents, medical histories, or clinical conditions were identified in the report in relation to this deficiency.
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