Unattended and Unlocked Wound Care Cart with Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored to prevent unauthorized access. On one of the survey days, a wound care cart located in the 200 Hall was observed to be unlocked and unattended for fifteen minutes, with wound cleanser left unsecured on top of the cart. The cart contained medications such as Nystatin, Santyl, Dakin's solution, and other wound care agents. The cart was only locked after a registered nurse returned, placed the unsecured cleanser inside, and secured the cart. Interviews with the registered nurse and the Director of Nursing confirmed that the cart should have been locked at all times when not in use, as per facility policy. The nurse explained that the keypad locking mechanism was malfunctioning, requiring manual locking, and admitted to forgetting to lock the cart after use. The Director of Nursing and the Administrator both acknowledged the expectation that all treatment carts remain locked and that no medications or supplies should be left unsecured.