Unattended and Unlocked Medication Cart with Accessible Medications
Penalty
Summary
Surveyors observed that the Unit 2-B nursing medication cart was left unlocked and unattended in a hallway, with a vial of Timolol eye drops for a resident placed on top of the cart. The drawers of the cart were found to be unlocked and contained various medications and medical supplies, including multiple insulin pens in use for several residents, lancets, pen needles, syringes, topical medications, and other items. The cart was positioned in front of a patient room, with its drawers easily accessible from the hallway. During interviews, the LVN responsible for the cart acknowledged that medications should be stored in locked carts and that the cart must be locked when not under direct supervision. She stated she left the medication on top of the cart and forgot to lock it because she was called away to assist another resident. The DON confirmed that facility policy requires medication carts to be locked and supervised at all times, and that failure to do so could result in unauthorized access to medications or injuries. Review of the facility's policy corroborated these expectations, stating that medication carts must never be left unlocked or unattended, and medications should not be left on top of the cart.