Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that medication carts were locked when unattended, as observed during a survey. A policy titled 'Storage of Medications,' revised in April 2019, mandates that all drugs and biologicals be stored securely, and specifically states that unlocked medication carts should not be left unattended. During an observation, a medication cart was found unlocked and unattended outside a room, with no staff or residents nearby. A Registered Nurse confirmed she was in a resident's room and out of eyesight from the cart, acknowledging that she should have locked it. The Director of Nursing also confirmed that medication carts should not be left unlocked and unattended.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: No residents were affected by the deficient practice. Nurse was immediately informed she left her med cart unlocked and locked it right away. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by the deficient practice, and therefore, a comprehensive review will be initiated to assess any potential risks associated with the handling of medications. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: On March 21, 2025, the Director of Nursing provided an in-service training for Licensed Nurses on the critical importance of ensuring that medication carts are locked when not in use. This training will reinforce the protocol that all medication carts must be secured properly when left unattended. How the facility plans to monitor its performance to make sure that solutions are sustained: Starting on March 21, 2025, Nursing Managers and Supervisors, including the Director of Nursing Services, Assistant Director of Nursing, Infection Preventionist, and Director of Staff Development, will begin conducting weekly audits at various times throughout the day to verify adherence to the policy requiring that medication carts are properly locked when not in use. The outcomes of these weekly audits will be discussed during monthly Quality Assurance and Performance Improvement (QAPI) meetings to ensure ongoing accountability and improvements are made as necessary. Include dates when corrective actions will be completed: March 21, 2025.