Unattended and Unlocked Medication Carts
Penalty
Summary
Multiple instances were observed where medication and treatment carts were left unlocked and unattended in resident care areas. On several occasions, medication carts were found unlocked in hallways with residents present or nearby, and in one case, a resident rolled past an unattended, unlocked cart in a wheelchair. Both prescription and non-prescription medications, including nystatin, were accessible in these unlocked carts. In another instance, four unidentified pills were found on top of an unattended, unlocked medication cart. Interviews with nursing staff revealed that they were aware of the facility's policy requiring carts to be locked when not in use or not in view, but admitted to forgetting to lock them, often due to being rushed or distracted. Further interviews indicated that some nurses kept keys to the medication carts inside the carts themselves, and there had not been recent in-service training on the policy. The Director of Nursing Services confirmed that carts should be locked when not in the nurse's visual contact and acknowledged that education on this policy had been provided. Review of the facility's Medication Administration Policy confirmed that keys should remain with the nurse at all times and that carts are never to be left unattended or unlocked in resident care areas.