Unattended and Unlocked Treatment Cart with Exposed Medications and Supplies
Penalty
Summary
During a random observation, a treatment cart containing tubes and bottles of biologicals, including medications for skin conditions and wounds, was found unlocked and unattended near the nurse's station, outside the main dining room, and close to the entry of a hallway. The top drawer of the cart was open, exposing insulin, blood glucose testing supplies, a box of exposed lancets, bottles of blood glucose strips, packaged dressings, and alcohol pads. Additionally, a plastic medication cup with unidentified pills and capsules was left unsecured on top of the cart. Eight residents were observed in the main dining room within view of the cart, and one resident was standing beside it. A visitor was also present near the unsecured cart, conversing with the resident for over two minutes while the cart remained unattended. The LPN responsible for the cart was inside the nurse's station, approximately twelve feet away and out of sight of the treatment cart. Upon noticing the situation, the LPN quickly secured the cart by closing the drawer, locking it, and moving it inside the nurse's station. The LPN later acknowledged that the cart should not have been left unlocked but stated she became distracted by another resident and forgot about it. Facility policy requires that medication carts and supplies be locked or attended by authorized personnel at all times, and that external medications be kept in a treatment cart or a separate, labeled drawer.