Unsecured Medication Cart and Failure to Dispose of Dropped Medication
Penalty
Summary
A medication cart located on the East Hall was observed to be unlocked and unattended on two separate occasions. The cart contained various medications, including antidepressants, controlled substances, routine daily medications, and insulin injectable pens. Facility policy required all medication carts to remain locked and secured when not in use. Both the RN and the DON confirmed that it was the responsibility of the floor nurse to ensure the cart was locked at all times. Additionally, a half yellow pill was found on the floor under the same medication cart. The RN admitted to dropping the pill, which was identified as sertraline (Zoloft) prescribed to a resident, and stated she did not pick it up because she was busy. The RN also failed to document the dropped medication on the resident's Medication Administration Record (MAR) or in the progress notes, as required by facility policy. The DON confirmed that dropped medications should be immediately picked up, disposed of in a Sharps container, and documented as not administered.