Medication and Treatment Carts Left Unlocked and Unattended
Penalty
Summary
A medication cart (Cart A) and a treatment cart (Cart B) were found unlocked, unattended, and out of the nurse's view during observations. Cart A was left unlocked near the nursing station with a resident seated across from it, and no staff were present in the area. Cart B was also found unlocked and unattended outside the secure unit double doors, with no staff nearby. Staff interviews confirmed that the expectation was for all medication and treatment carts to be locked when not in use or out of sight, but the responsible nurse admitted to forgetting to lock Cart A and indicated that Cart B may have been left unlocked by another nurse during wound care. The Director of Nursing and Assistant Director of Nursing both acknowledged that the carts should not have been left unlocked and that all staff were responsible for securing them. Record review showed that the resident seated near Cart A had a diagnosis of unspecified dementia, which could increase the risk of harm if medications were accessed. Facility policy required medication carts to be kept closed and locked when out of sight of the nurse, and all sides of the cart to be inaccessible to residents or others passing by. The unlocked carts contained medications and treatment supplies, including items such as betadine, which staff noted could pose a safety risk if accessed by residents.