Unattended and Unlocked Medication Cart Observed
Penalty
Summary
A medication cart (Medication Cart #1) was observed unlocked and unattended on the 100-hall for an extended period during a continuous observation. Multiple staff members, including nurse aides, a human resources staff member, an occupational therapist, and a maintenance staff member, walked past the unattended and unlocked cart. One resident was also present in the hallway, three rooms away from the cart, before entering a nearby room. The cart remained unlocked and unattended from at least 8:30 AM until 8:41 AM, when the Unit Manager noticed the issue and locked the cart. Interviews with the Unit Manager, the nurse responsible for the cart, and the Director of Nursing confirmed that the cart should have been locked when unattended. The nurse responsible stated she thought she had locked the cart and was unsure why it was left unlocked. The Unit Manager and Director of Nursing both acknowledged that leaving the cart unlocked and unattended was a safety hazard, as it allowed access to medications and resident information by unauthorized individuals.