Unlocked Treatment Cart with Medications and Needles Left Unattended
Penalty
Summary
A treatment cart on the 3 South Unit was found unlocked and unattended, containing prescribed topicals, ointments, wound cleaning agents, and hypodermic needles. Observations showed that the drawers of the cart were accessible to anyone passing by, including residents, with no licensed staff present in the area. Items found in the cart included a tube of topical pain gel, three bottles of Dakin's solution, multiple tubes of Medi honey, iodine swabs, five bottles of nystatin powder, several hypodermic needles, and various wound bandages. The facility's policy requires that medications and biologicals be stored properly and only accessible to licensed nursing personnel, with supplies remaining locked when not in use or unattended. Interviews with staff confirmed that the expectation was for treatment carts to always be locked when not in use. The Registered Nurse on duty was stationed elsewhere and did not have the cart in view, and the Assistant Director of Nursing Services/Infection Preventionist reiterated that treatment carts should always be locked. The Director of Nursing Services was unaware that the cart had been left unlocked and unattended for 22 minutes. Residents were observed moving past the unlocked cart during this time.