Unattended and Unlocked Medication Carts; Undated Opened Medications
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked when unattended and that medications were properly dated when opened. During random observations on three of seven nursing units, surveyors found multiple instances of unattended and unlocked medication carts containing resident medications. On one unit, a medication cart was left unlocked outside a resident's room while the LPN was inside the room. On another unit, a medication cart was left unlocked at the nurse's station while the LPN and unit secretary were occupied with other tasks, allowing the surveyor to access medications, including a Heparin vial. On a third unit, a medication cart was left unlocked in the hallway with the keys on top, and the surveyor was able to access insulin pens in the top drawer after the nurse walked away. Additionally, several insulin pens belonging to different residents were found in the unlocked cart without dates indicating when they were opened, despite the requirement that insulin pens are only good for 28 days after opening. The LPN present was unable to accurately date the insulin pens, as she was not the one who had administered them. The facility's medication storage policy requires that medication carts be locked or attended by authorized personnel at all times, but this was not followed during the observations.