Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on Unit 2 was found unlocked and unattended in a hallway across from the nurses' station. No nurse or medication aide was present in the vicinity at the time of observation. Staff interviews revealed confusion regarding the location of the medication cart keys, with one medication aide stating she did not have the keys and believed the nurse had them, while the nurse stated she had briefly handed the keys to another nurse. The nurse who had counted the cart and received the keys from the night shift was unsure how the cart was left unlocked. Staff acknowledged that the cart should remain locked at all times when not in use and recognized the risk of leaving it unsecured. The facility's policy requires that medications and biologicals be stored securely and only accessible to authorized personnel, with medication carts locked or attended at all times. The incident involved a failure to adhere to this policy, resulting in the medication cart being left accessible for an unknown period. No specific residents were identified as being directly involved or affected at the time of the deficiency.