Unattended and Unlocked Medication Cart Due to Malfunctioning Lock
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all drugs and biologicals were stored securely and locked in accordance with professional standards. During an observation, a medication cart assigned to the 800 hall was found unattended and unlocked in a hallway, with drawers containing various medications such as acetaminophen, aspirin, docusate, and vitamin C accessible. The nurse assigned to the cart, an LVN, stated that the lock on the cart had malfunctioned and had not reported the issue since the start of her shift, assuming the facility was already aware of the problem. The cart remained unsecured and unattended, out of the nurse's line of sight, allowing potential unauthorized access to medications. Interviews with facility staff revealed that the ADON was not aware of the malfunctioning lock, and the DON confirmed that the expectation is for medication carts to be locked whenever unattended, with immediate reporting required for any malfunctions. Despite a request, the facility did not provide a policy regarding medication cart security by the time of the report. The failure to secure the medication cart and promptly report the malfunction led to a lapse in the safe storage of drugs and biologicals.