Unsecured Medication and Insulin Carts Observed Unattended
Penalty
Summary
Surveyors observed that the facility failed to secure medications on two separate medication carts: a wound care cart containing topical medications and a blood glucose cart containing insulin. On one occasion, two nurses prepared and administered wound care to a resident while leaving the wound care cart unlocked and unattended in the hallway, with the lock extended outward and covered in tattered medical tape. The cart, which contained various topical medications and wound care solutions, was left out of sight of the nurses while they were inside the resident's room, and self-propelling residents in wheelchairs were present nearby. Interviews with the nurses revealed that the wound care cart had been left unlocked for several weeks due to a lack of a key, and the Director of Nursing was unaware of the reason for the tape on the lock or the lack of access to a key for the wound care nurse. In a separate incident, the blood glucose cart was found unattended in a hallway with the lock extended and the key inserted. This cart contained insulin flex pens for sixteen residents. The nurse responsible for the cart confirmed that it should have been locked when unattended but could not provide a reason for leaving it unlocked with the key in place. The Director of Nursing also confirmed that the insulin pens were stored on the cart and that the key should have remained with the nurse at all times when the cart was unattended. Throughout these observations, it was noted that both medication carts were left unsecured in areas accessible to residents, and staff interviews confirmed a lack of adherence to proper medication storage protocols. The failure to secure these carts was directly observed by surveyors and acknowledged by the staff involved, with no immediate explanation or corrective action provided at the time of the incidents.