Unsecured Medications Left on Top of Medication Cart
Penalty
Summary
During an observation of the medication cart in the hallway near a resident room, an intravenous (IV) bag of vancomycin and a bottle of vitamin D3 were found sitting unsecured on top of the cart. At the time, a housekeeper was present in the area, and the cart was not under the direct supervision of a nurse. The medications were accessible to anyone in the vicinity, including residents, visitors, or unlicensed staff. The LPN responsible for the cart was not in sight and only returned several minutes later to secure the medications after the surveyor's observation. Interviews with the LPN and the Director of Nursing confirmed that the medications should not have been left on top of the cart and that facility policy requires all medications to be kept locked in the medication cart. The facility's policy also emphasizes the importance of medication security, particularly given the presence of many residents with dementia. The failure to store medications securely was directly observed and acknowledged by staff.