Unattended and Unlocked Medication Cart with Improper Disposal of Oral Syringes
Penalty
Summary
Surveyors observed an unattended and unlocked medication cart near the C and D Halls of the facility during early morning hours. On top of the cart, there was a clear plastic drinking cup containing two small oral syringes, which had been used to administer morphine sulphate. Small droplets of an unknown clear substance were present on the syringes and inside the cup. No staff were present in the area at the time of observation. Shortly after, an LPN exited a resident's room at the far end of the D Hall and confirmed that the medication cart was left unlocked and unattended. The LPN stated that the syringes were left by the night shift and that she was attempting to clean up the mess, noting that shift change had occurred approximately one hour prior. The facility's policy on medication storage, revised in January 2024, requires that all medications be stored securely and that medication carts remain locked or under direct observation during medication passes. The failure to secure the medication cart and properly dispose of used oral syringes was found to have the potential to affect seven residents identified as cognitively impaired and independently mobile, all residing on the C and D Halls. This deficiency was identified during a complaint investigation.