Failure to Secure Medication Carts and Medications
Penalty
Summary
Staff failed to store drugs and biologicals in accordance with state and federal requirements, specifically by leaving medication carts unlocked and unattended on the Pleasant View unit. On multiple occasions, a nurse was observed walking away from an unlocked medication cart, leaving it accessible in the hallway while out of sight, with residents and staff passing nearby. The surveyor was able to open the cart and access medications during these periods of inattention. The facility's policy requires that medication carts be locked and accessible only to authorized personnel, but this was not followed during the observed medication pass. Additionally, the nurse was seen removing medications from the cart and placing them on top of the cart before walking into a resident's room, leaving the medications unattended and out of sight. This occurred more than once, with both residents and staff observed walking by the unattended medications. During interviews, both the nurse and the Director of Nursing acknowledged that medication carts must be locked when unattended and that medications should not be left on top of the cart or left unsecured.