Unattended and Unlocked Wound Care Cart with Medications
Penalty
Summary
A wound care treatment cart was observed left unlocked and unattended in a hallway for approximately 20 minutes while a registered nurse entered a resident's room to perform wound care with the door closed. The facility's policy requires that medication carts remain closed and locked when out of sight of the administering nurse or aide, and that no medications are kept on top of the cart. During the observation, the cart contained items such as bactericidal isopropyl alcohol-based sanitizer wipes, Santyl ointment, normal saline, betadine, and nail clippers. The registered nurse confirmed that the cart was left unlocked and unattended, acknowledging that it should have been secured to prevent resident access. The Director of Nursing also confirmed that staff are expected to keep carts locked and not leave them unattended, citing risks such as possible resident poisoning from substances like betadine or Santyl, and unauthorized access by untrained staff. The incident was found to be out of compliance with both facility policy and regulatory requirements for the secure storage of drugs and biologicals.