Medication Cart Left Unlocked and Unattended During Medication Pass
Penalty
Summary
A deficiency was identified when a nurse failed to secure the medication cart on two separate occasions while administering care to a resident with diabetes. During an observation, the nurse took supplies from the medication cart to perform a blood sugar check in the resident's room, leaving the cart unlocked and unattended in the hallway. After returning to the cart to obtain an insulin pen, the nurse again left the cart unlocked while re-entering the resident's room. The nurse acknowledged that the cart should have been locked when unattended and admitted to not following this protocol. The Director of Nursing confirmed that staff are expected to lock the medication cart whenever it is left unattended, as the cart contained several medications. Review of the facility's policy also indicated that the medication cart must be locked if left at any time during medication pass. The failure to secure the medication cart was observed and confirmed through interviews and record review, specifically involving a resident with diabetes who was receiving insulin as ordered.