Unattended and Unlocked Medication Cart with Unsecured Medications
Penalty
Summary
Facility staff failed to ensure that medications and medication carts were properly secured in accordance with facility policy and accepted professional standards. During an observation, a medication cart was found unattended and unlocked, with a glucometer and lancets left in an open tray on top of the cart. A certified nursing assistant had to locate the nurse responsible for the cart, who confirmed that the cart should always be locked when not in the nurse's sight. Additionally, a nurse was observed leaving medications on top of the unlocked cart while entering a resident's room to administer medication, during which time the cart was not visible to the nurse. The nurse acknowledged that medications should not be left unattended and that the cart should be locked. Further interviews with staff, including the DON and Executive Director, confirmed that facility policy requires medication carts to be locked when out of sight and that medications should not be left unattended. Despite this, the nurse left a resident's refused medication in a plastic bag on top of the unlocked cart and left the area, stating she needed to use the bathroom. These actions were inconsistent with facility policy and resulted in medications and the medication cart being left unsecured and unattended.