Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart located on hall two was observed multiple times to be left unlocked and unattended at the nurses station. During a series of observations, the unlocked cart was passed by a visitor, two unlicensed staff members (CNAs), two housekeepers, and a resident, all of whom had the opportunity to access the medications inside. The cart remained unsecured for at least 20 minutes until LVN C returned and locked it. LVN C acknowledged that leaving the cart unlocked could result in drug diversion or harm if accessed by unauthorized individuals, including confused residents. Interviews with the Administrator and the DON confirmed that it is facility policy for medication carts to be locked when unattended and that only authorized personnel should have access. The facility's Medication Storage policy also requires all drugs and biologicals to be stored in locked compartments and only accessible to authorized staff. The failure to secure the medication cart was attributed to LVN C, who had been employed at the facility for two weeks and had two years of nursing experience.