Unattended and Unlocked Treatment Cart with Medications
Penalty
Summary
A deficiency occurred when a nursing treatment cart containing drugs and biologicals was left unlocked and unattended by the Treatment Nurse. During the provision of wound care to a resident with heart failure, high blood pressure, and an open wound on the right toes, the nurse entered the resident's room to wash her hands, leaving the cart in the hallway, out of her line of sight, and in an unlocked state as indicated by the visible red portion of the lock handle. The nurse subsequently removed betadine from the cart to apply to the resident's toes and continued to leave the cart unlocked while providing wound care, only locking it after completing the treatment and retrieving another item from the cart. Interviews confirmed that the Treatment Nurse believed she had locked the cart, as was her usual practice, but observations showed otherwise. The Director of Nursing (DON) stated that the cart should be locked when unattended to prevent unauthorized access to medications. Review of facility policy confirmed that all compartments containing drugs and biologicals must be locked when not in use and not left unattended if open or accessible.