Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on both the 200 and 300 halls were left unlocked and unattended on multiple occasions. On the 200 hall, a medication cart was found unlocked and unattended in the hallway, and the assigned LVN admitted to forgetting to lock it. The LVN acknowledged that leaving the cart unsecured could allow unauthorized persons to access medications, potentially leading to consumption of drugs not prescribed to them. On the 300 hall, the medication cart was also observed unlocked and unattended twice, and the assigned respiratory technician later locked it after being observed. The technician admitted to forgetting to lock the cart and recognized the risk of unauthorized access to respiratory and oxygen treatment medications. Interviews with staff, including the DON and unit manager, confirmed that facility policy requires medication carts to be locked when not in use to prevent unauthorized access, especially given the presence of residents who wander. Review of facility policy documents corroborated this expectation, stating that medication carts must be securely locked at all times when out of the nurse's view. The repeated failure to secure medication carts as required constituted a deficiency in the facility's medication storage practices.