Unattended and Unsecured Medication Cart During Medication Pass
Penalty
Summary
Surveyors observed that medication storage and security protocols were not followed during a medication pass. A bottle of aspirin 81 mg and a bottle of Lactobacillus 100 mg, both intended for a specific resident, were left on top of an unlocked medication cart. The cart was left unattended in the hallway by a registered nurse while the nurse administered medications in residents' rooms, at times with the door closed. During this period, both staff and residents passed by the unattended cart. The nurse later confirmed that the medications should have been secured and that the cart should have been locked when not attended. Facility policies require that only authorized personnel have access to medications and that medication carts are locked or attended at all times. The policies also specify that the cart must be locked before entering a resident's room and that medications should never be left on top of the cart. The Director of Nursing acknowledged awareness of the incident and confirmed that the observed practices did not align with facility policy.