Unsecured Treatment Cart and Improper Medication Storage
Penalty
Summary
Surveyors observed that a treatment cart containing medications used for wound care was left unattended and unlocked in a hallway for 25 minutes. During this time, no staff were present with the cart, and several staff members, visitors, and a resident in a wheelchair passed by the unlocked cart. Upon inspection, the cart was found to contain several topical medications, including antiseptic solution, medical grade honey, hydrocortisone cream, corticosteroid cream, and a cream for skin conditions. The Wound Care Nurse acknowledged forgetting to lock the cart and confirmed that these medications could be dangerous if accessed by a cognitively impaired resident. Both the DON and the Administrator confirmed that the cart should have been locked at all times when not in use, as the medications could pose a danger if ingested. Additionally, surveyors found that Astelin nasal spray, which must be stored upright according to manufacturer instructions, was stored horizontally in two separate medication carts. Nurses responsible for these carts admitted they had not read the manufacturer's instructions and were unaware of the proper storage requirements. The DON stated that nursing staff are expected to check carts and follow all manufacturer guidelines for medication storage, including storing the nasal spray upright if indicated.