Failure to Secure Medication Carts and Protect PHI
Penalty
Summary
Surveyors observed that three out of six medication carts in the facility were left unlocked and unsupervised, contrary to facility policy and accepted professional standards. On one occasion, an unlocked medication cart and an unsecured treatment cart containing prescription medications, stock medications, insulin, and treatment supplies were found unattended in the Blue Hall. A Certified Medication Aide later secured the carts and confirmed that staff were expected to lock them when not directly supervising. In another instance, an unsecured treatment cart containing stock medications, treatment supplies, and insulin was found outside a resident's room in the Red Hall. The cart's laptop was open, displaying a resident's picture and protected health information in direct view. A Licensed Nurse present was unsure about the locking requirements for medication carts but acknowledged that PHI should not be left open on computers when not in use. The facility's policy, revised in January 2021, requires that all drugs and biological agents be stored in locked compartments or areas and that staff supervise medications and biologicals during administration or use. Administrative staff confirmed that staff receive annual training on medication storage and resident safety expectations. Despite these policies and training, the observed lapses in securing medication carts and protecting PHI led to the identified deficiency.