Unattended Narcotic Medication Left on Medication Cart
Penalty
Summary
A narcotic medication, specifically Lorazepam, was observed left unattended in a plastic medication cup on top of a medication cart in the common area of the secure unit. The cup, labeled with a resident's name and containing a white substance submerged in liquid, was left next to a plastic drinking cup of tan colored liquid. This situation occurred while there were seven residents present in the room, including one resident who was ambulatory, and a CNA who was not monitoring the medication cart. The medication and supplement remained unattended and out of staff line of sight for a total of 37 minutes, during which time staff and visitors moved in and out of the area. Interviews with staff confirmed that the assigned nurse, RN R, had left the medication unattended while off the unit for approximately 15 minutes. RN R acknowledged the medication was a prescription narcotic intended for a resident present in the area and admitted it should not have been left unattended. Additional staff interviews and review of facility policy confirmed that medications, especially controlled substances, are required to be under direct observation or locked at all times. The facility's policy also specifies that all drugs and biologicals must be stored in locked compartments, and controlled substances must be double-locked, which was not followed in this instance.