Medication Cart Security and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medication carts were kept locked when not in use and that medications were properly stored, as observed with two medication carts. On February 9, 2025, at 8:35 a.m., Medication Cart A was found unlocked and unsupervised in the hall of the second floor, with a bottle of over-the-counter aspirin placed on top. Employee E7, a licensed nurse, confirmed that the cart was her responsibility and admitted to leaving it unattended to assist a resident. Similarly, Medication Cart B was observed during a medication pass at 8:49 a.m. on the same day. The cart was found with a bottle of over-the-counter mucus relief expectorant being used to support the medication cart computer. Employee E23, another licensed nurse, confirmed that the medication bottle was not being used appropriately. These observations indicate a failure to adhere to the facility's medication storage policy, which requires medication carts to be locked when not in use and attended by authorized personnel.
Plan Of Correction
1. No resident was adversely impacted due to unsecured medications in an unattended, unlocked medication cart. Employee E7 and E23 were re-educated by NPE on Medication Cart Safety/Management to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 2. NPE or designee to conduct an initial house audit to ensure all medication carts are locked and free from unsecured medications. 3. NPE or designee will re-educate all licensed nurses on Medication Cart Safety/Management to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 4. DON or designee will conduct 5 random weekly audits x 12 weeks to ensure medications are secured and not left unattended on top of the med cart and med carts are locked while unattended. 5. DON or designee to review the results of these audits at the monthly QAPI meeting x 3 months.