Medication Cart Left Unlocked and Unattended During Administration
Penalty
Summary
A medication cart on A Hall was observed to be intermittently left unlocked and unattended by a certified medication aide (CMA) during medication administration rounds. The cart was left facing the hallway and unattended from 7:15 AM to 7:43 AM while the CMA entered resident rooms to dispense medications. The CMA, who was a prn employee and had not worked at the facility for a month, stated this was her third time passing medications alone at the facility. She acknowledged being trained to lock the medication cart and recognized the risks associated with leaving it unlocked. Interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that facility policy requires medication carts to be locked whenever unattended. They each stated that an unlocked cart could allow residents, visitors, or staff to access medications, which could result in ingestion of medications without supervision. Review of the facility's Pharmacy Policy and Procedure Manual also indicated that the medication cart must always be in full view of the nurse during administration and must be completely locked after the process is completed.