Unattended Medications Left on Medication Cart
Penalty
Summary
A deficiency occurred when a nurse left a resident's medication blister cards unattended on top of a medication cart in the hallway, while she entered another resident's room with the door closed. The unattended medications included Buspirone, Pantoprazole, Gabapentin, Escitalopram, Dantrolene, and Metoprolol, all clearly labeled with the resident's identifying information. The medication cart was left in front of the resident's doorway and was unattended for about one minute, during which time the medications were accessible to anyone passing by. The resident involved was a male with multiple complex medical conditions, including atrial fibrillation, hypertension, renal insufficiency, diabetes, aphasia, CVA/TIA, hemiplegia, malnutrition, anxiety, and dysphagia. He was dependent on staff for activities of daily living and received several scheduled medications via G-tube. The nurse stated she had just administered the resident's medications when she heard another resident calling for help and left the medication cards on the cart while she attended to the other resident's needs. Interviews with other nursing staff and facility leadership confirmed that medications are required to be locked in the medication cart at all times when not being administered, and that leaving medications unattended is against facility policy. Staff acknowledged that leaving medications out could result in unauthorized access to medications and resident information. Facility policies and staff statements consistently indicated that only licensed nurses and certified medication aides are permitted access to medication carts, and that all drugs and biologicals must be stored in locked compartments when not in use.