Medication Carts Left Unlocked and Unattended in Accessible Areas
Penalty
Summary
Three medication carts were observed unlocked and unattended in common areas accessible to residents, staff, and visitors. On multiple occasions, medication aides and nurses left carts unsecured while attending to residents in nearby rooms. In one instance, a medication aide admitted she thought she had locked the cart, but was able to open it without a key, revealing multiple containers of over-the-counter medications. Another nurse stated she had to leave the cart unlocked because the keypad lock was inoperable and she did not have a key, while a medication aide held the key. The Director of Nursing (DON) was present during one of these observations and instructed the nurse that the cart could not be left unlocked and unattended. Facility policy requires that medication carts be secured during medication passes and locked at all times when out of the nurse's view. Interviews with staff and the DON confirmed that the carts should have been locked and that leaving them unsecured could allow unauthorized access to medications. The observations and staff statements indicate that the facility failed to ensure all drugs and biologicals were stored in locked compartments and permitted only authorized personnel access, as required by policy.