Unattended and Unlocked Treatment Cart
Penalty
Summary
Surveyors observed that Treatment Cart #1 was left unlocked and unattended near the nurses' station, positioned between two wings of the facility. The cart contained bandages, prescription creams, scissors, gauze, iodine, honey patches, and saline. There were residents present in the immediate area, and no staff were at the nurses' station at the time. The cart remained unlocked and unattended for at least five minutes, during which time all drawers were accessible. The facility's policy requires that medication carts be kept closed and locked when out of sight of the medication nurse, and that no medications be kept on top of the cart. Interviews with the Administrator and Assistant Director of Nursing (ADON) confirmed that the treatment cart should have been locked at all times and that all nurses are responsible for ensuring this. The ADON was unable to determine which nurse left the cart unlocked and stated that all nurses had been in-serviced on the importance of keeping treatment carts locked. The facility's policy and in-service documentation both emphasized the requirement to keep medication carts locked and secured when not in use to prevent unauthorized access.