Medication and Treatment Carts Left Unlocked and Unattended on Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when medication and treatment carts were left unlocked and unattended on the locked memory care unit. During an observation, both carts were found unsupervised and unlocked at the nurses' station, with no staff present in the immediate area. The only staff member on the unit at the time, a CNA, was serving breakfast trays in the dining room, while the LPN was downstairs administering medications. This left the medication and treatment carts accessible and out of view of any staff. Medical record reviews confirmed that seven residents on the memory care unit were severely impaired in daily decision-making, ambulatory, and capable of independently moving throughout the unit. Interviews with staff verified that these residents wandered the unit and could open the drawers of the carts. Facility policy required that medication carts be locked when out of sight or unattended, a standard not met during the observed incident.