Unattended and Unlocked Medication Cart Exposes Medications
Penalty
Summary
A deficiency was identified when a medication cart in the 100 Hall was found unlocked and unattended in the hallway, exposing its contents to unauthorized access. The cart contained over-the-counter (OTC) medications, prescription medications, syringes, more than 30 lancets, and over 100 pen needles, as well as inhalation solutions, inhalers, and topical creams. The cart was left unattended by an LVN who stated she was interrupted by a resident request during medication pass, resulting in the cart being left unlocked and unsupervised. Interviews with the LVN and the Interim DON confirmed that facility policy requires medication carts to be locked when not in use and under direct supervision, to prevent unauthorized access, especially by cognitively impaired residents. Review of the facility's Medication Management policy further supported this requirement, stating that medication carts must be locked when not in use and that keys are to be kept with authorized staff. The failure to secure the medication cart was observed directly by surveyors and acknowledged by staff.