Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart assigned to hall 300 was observed parked in the hallway with its drawers facing outward and left unlocked. The centralized, metal, round lock on the cart was protruding, indicating it was not secured, and the drawers could be easily opened. The cart contained various over-the-counter medications, blister packs, and insulins. During this time, several staff and residents passed by the unlocked cart. Approximately five minutes later, an RN returned to the cart after responding to a resident's call light and acknowledged that he had forgotten to lock the cart before leaving it unattended. In interviews, the RN admitted to forgetting to secure the cart and recognized that leaving it unlocked allowed anyone, including residents, staff, and visitors, to access the medications. The DON confirmed that medication carts are required to be locked at all times when unattended to prevent unauthorized access. Review of the facility's policy on medication storage, revised in May 2021, reflected that drugs and biologicals should not be left unsecured or unattended, and that medication carts must be kept locked when not in use.