Medication Cart Left Unlocked and Unattended in Memory Care Unit
Penalty
Summary
A deficiency occurred when Medication Cart #1 was found unlocked and unattended in an open, unlocked office within the memory care unit. At the time of observation, all residents were in their rooms, and two CNAs were present in the hallway. One CNA stated she was unaware that the medication cart was unlocked, did not know how long it had been left that way, and did not know how to lock it. The Charge Nurse later acknowledged that she had accessed the cart earlier to add new medications and must have forgotten to lock it afterward. The facility's policy requires that medication carts be locked and secured when not in use, and that only authorized personnel have access to medications. The failure to secure the medication cart was confirmed through interviews with staff, including the CNAs, the Charge Nurse, the Administrator, and the DON. All acknowledged that the unlocked cart could have allowed residents access to medications. The facility's written policy also specifies that medications must be stored in locked compartments and that the cart should remain locked when unattended, which was not followed in this instance.