Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure the safe storage of medications as required, specifically by leaving a medication cart unlocked and unattended on the west unit. Multiple observations showed a resident with severe cognitive impairment and a history of fidgeting with items accessing the medication cart and its contents while staff were not present. The resident was seen sitting at, touching, and retrieving items from the medication cart, including supplement drinks, and was able to remove and conceal items in his wheelchair. At times, the medication cart was left in the hallway, unlocked, and out of the direct line of sight of nursing staff. Interviews with staff, including the LPN, ADON, DON, and consultant pharmacist, confirmed that the expectation was for medication carts to be locked whenever not in use or when the nurse was not in direct control of the cart. Staff acknowledged the resident's tendency to wander and pick up items, and confirmed that the cart was left unlocked for several minutes while unattended. The facility was unable to provide a policy regarding medication cart security when requested.