Unattended and Unlocked Medication Cart with Open Drawer
Penalty
Summary
A medication cart on hall 300 was observed to be left unattended, unlocked, and with a drawer partially open containing resident medications for a period of two minutes. During this time, two staff members walked past the cart, but no residents were observed near it. The medication aide assigned to the cart confirmed that she had walked away from the cart without locking it or closing the drawer, stating she was in a hurry and forgot to secure the cart. Interviews with the medication aide, a nurse, the Director of Nursing, and the Administrator all confirmed that facility policy and training require medication carts to be locked and drawers closed when unattended. The staff involved acknowledged awareness of this requirement and confirmed that the medication aide had received annual training on this policy. The incident was attributed to the aide becoming distracted and failing to follow established procedures for securing medications.