PruittHealth-Bamberg: Narcotic Sheets Missing, Nurse Suspended - SC
That detail surfaced during a federal complaint inspection completed August 25, 2025, one that centered on missing narcotic sheets, a suspended nurse, and a medication handoff that fell apart somewhere between a ringing phone and a set of cart keys left on a counter.
The nurse who wasn't there, identified in inspection records as LPN3, told inspectors she knew little about what had happened. "I was called to write a statement," she said. "I heard my signature was used, but I didn't work that day, and I didn't sign for anything because I wasn't there."
The nurse who was suspended, LPN1, described her first day back from illness as the shift in question. She told inspectors she counted the narcotic sheets and marked off medications as narcotics were given. Highlighted sheets indicated completion. At the end of her shift, she said, she returned the medications and narcotics to the cart. "I don't know the normal practice of removing medications from the medication cart," she said. "That was my first day back from being sick." The next morning, she was asked to write a statement. Then she was suspended. As of the inspection date, she remained on suspension.
A third nurse, LPN4, gave inspectors the most detailed account of what happened in the hours before the sheets went missing. Four nurses were working that day, one more than usual. Around 6 p.m., LPN1 told LPN4 she was finished with her work and began cleaning LPN4's cart. LPN4 pulled her own narcotics out to review her sheets at the nursing desk and asked LPN1 to come over and verify the count.
LPN1 didn't respond. Her phone rang. She set her cart keys on the medication cart and told LPN4 she had to take the call.
"I kind of hesitated to take her medication cart keys," LPN4 told inspectors. "I wouldn't leave my keys with another nurse." She replaced the medications in LPN1's cart. As far as she knew, both counts were correct. At 2 a.m., she received a call saying narcotic sheets were missing.
LPN2, who took over the cart afterward, told inspectors the count was accurate when she came on. All narcotic sheets were accounted for. She described the standard procedure: one nurse counts, another counts behind her, the unit manager zeros out the previous sheet. The day shift, she said, had simply forgotten to add new narcotic medications to the narcotic card. "We add the cards as they come in at night."
The facility's Director of Health Services told inspectors that unit managers check narcotic sheets weekly. She checks them monthly. The administrator said nurses are required to sign narcotics on both the paper record and the medication administration record, with the DHS responsible for checking off narcotic sheets.
After the incident, the facility implemented a new narcotic log sheet requiring nurses to enter counts at each shift change and sign off. LPN3 noted the change directly: "They implemented the log to count the narcotic cards."
Federal inspectors cited the facility under F0755, which covers medication management, finding the potential for harm to many residents. The citation was tagged at a level of minimal harm or potential for actual harm.
What the inspection record does not resolve is whose signature appeared on LPN3's behalf, how narcotic sheets went missing after two nurses believed their counts were correct, or what the investigation into LPN1's suspension ultimately found. Those answers, if they exist, are not in the inspection report.
What is in the report is a nurse who set her keys on a cart and walked away to answer a phone, another nurse who hesitated to pick them up, and a third nurse who came in the next morning to find her name on paperwork from a shift she never worked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pruitthealth- Bamberg from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
PruittHealth- Bamberg in Bamberg, SC was cited for violations during a health inspection on August 25, 2025.
The nurse who wasn't there, identified in inspection records as LPN3, told inspectors she knew little about what had happened.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.