Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart located by the nurse's station was found unlocked and unattended during an observation. The surveyor was able to open the top drawer and noted that multiple medications in bulk bottles and blister packs were easily accessible. The registered nurse (RN) responsible for the cart was sitting behind the nurse's station and acknowledged responsibility for the unlocked cart. The RN stated that the cart should be locked at all times to prevent unauthorized access but admitted to forgetting to lock it after retrieving items and then going to chart at the nurse's station. Interviews with the RN and the Director of Nursing (DON) confirmed that staff are regularly in-serviced on the requirement to keep medication carts locked when not in use, and that the DON makes frequent rounds to ensure compliance. A review of the facility's Storage of Medications policy also reflected the requirement for all compartments containing drugs and biologicals to be locked when not in use. Despite these policies and procedures, the medication cart was left unlocked and unattended, making medications accessible to unauthorized individuals.