Medication Cart Keys Left Unsecured During Shift Change
Penalty
Summary
A deficiency occurred when the facility failed to ensure that only authorized personnel had access to the keys for a medication cart serving Halls 400/500/600. During an observation, the medication cart was found locked, but the keys were left inside a closed medication count binder placed on top of the cart. The keys were accessible upon opening the binder, and the surveyor was able to use them to open the cart. Interviews revealed that the keys were routinely left in the binder, especially during shift changes when the medication aide was not present at the scheduled time. The night nurse did not count the cart with the oncoming medication aide, and the keys were left in the binder for the aide to retrieve later. Further interviews with staff, including the RN, medication aide, and DON, confirmed that the facility's policy required the keys to be in the physical possession of authorized personnel at all times and not left unattended. The DON acknowledged that leaving the keys in the binder was not acceptable, as it allowed unauthorized access to medications. The facility's policy on medication labeling and storage specified that only authorized personnel should have access to the keys, but this protocol was not followed during the shift change process.