Unsecured Medication Carts Observed on Two Hallways
Penalty
Summary
Surveyors observed that two medication carts, located on the upper and lower 100-hall, were left unlocked and unattended in the hallway. On the upper 100-hall, a resident's insulin pen was found sitting on top of the unlocked cart, with the bottom drawer open, while two Nursing Assistants walked past without intervening. The nurse responsible for this cart acknowledged that she failed to secure the medications before leaving to administer medication to a resident. On the lower 100-hall, the medication cart was also found unlocked and unattended, with two Nursing Assistants passing by. The nurse responsible, an agency nurse, admitted she was aware of the requirement to lock the cart but did not do so. Interviews with facility leadership revealed a lack of clarity regarding staff education and oversight responsibilities. The DON stated that the Quality Assurance Nurse was responsible for education but was unsure what training had been provided. The Quality Assurance Nurse indicated that Unit Managers were tasked with educating staff but did not know what specific education had occurred. The Administrator emphasized the need for staff accountability but could not explain why the nurses left the carts unlocked.