Medication Carts Left Unlocked and Unattended by Staff
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked and secure, as required by facility policy and professional standards. On two separate occasions, a medication aide and an LVN left their respective medication carts unlocked and unattended while administering medications or attending to residents in other rooms. Observations confirmed that the locks on both carts were disengaged, with visible indicators showing the carts were unlocked. In one instance, a resident in a wheelchair approached the unattended cart, seeking pain medication, while the medication aide was in another room. The aide acknowledged awareness of the requirement to keep the cart locked but admitted to forgetting and leaving it open. In the other instance, the LVN left syringes and vials of unknown medication on top of the unlocked cart and stated that she routinely left the cart unlocked during medication passes for convenience, despite knowing the policy. Review of the medication carts revealed that they contained various prescription medications for residents, including drugs for depression, high blood pressure, thyroid issues, seizures, and nausea. Both staff members interviewed recognized that leaving the carts unlocked could allow unauthorized access to medications. The interim ADON confirmed that it was the expectation for medication carts to be locked when not in use and that staff using the carts were responsible for ensuring their security. Facility policy also required that medication carts be locked at all times when out of the nurse's view.