Unattended Unlocked Medication Cart with Accessible Syringes and Iodine
Penalty
Summary
A medication cart on nursing station 4 was found unlocked and unattended, with drawers open and accessible to residents, including those with dementia who were present in the adjacent hallway. The cart contained six 1-ml hypodermic syringes and a 12-ounce bottle of povidone iodine with a broken cap and visible residue. No staff intervened as the cart was inspected, and the closest nurse was unaware of the responsible nurse's whereabouts. The facility's policy requires all medication carts to be locked when unattended. Interviews with staff revealed that the nurse responsible for the cart had left early for a family emergency, and the cart was shared among various nursing staff for wound treatments. Staff acknowledged awareness of the policy and previous incidents of the cart being left unlocked, particularly when the regular treatment nurse was on vacation. The facility had previously been cited for a similar issue with the same cart and location.