Unattended and Unlocked Medication Carts
Penalty
Summary
Facility staff failed to ensure that medication carts containing drugs and biologicals, including narcotics, were securely locked and attended as required by facility policy and professional standards. On two separate occasions, a medication cart on the 100-hall and a respiratory therapy medication cart on the 200-hall were observed left unattended, unsupervised, and unlocked in the hallways. The 100-hall cart was left unlocked for 10 minutes while residents and CNAs walked by, and the 200-hall cart was left unlocked for 5 minutes with similar hallway traffic. In both cases, the responsible staff members were not present, and the carts were accessible to unauthorized individuals. Interviews with facility staff, including the ADON, LVN, and RT, confirmed that the carts were left unlocked due to human error and lack of awareness of the assigned nurse's whereabouts. The facility's policy requires medication carts to be locked when not in use or out of the nurse's view, and to be parked securely when unattended. The DON acknowledged that the expectation is for all medication carts to be locked when not attended by nursing staff.