Failure to Secure Medication Cart and Medications
Penalty
Summary
A deficiency was identified when drugs and biologicals were not stored in locked compartments as required. During an observation, a medication cart was found unlocked in the Southwest corridor with a set of keys hanging from the lock and no staff present. At the time, three residents were independently moving in the hallway, and the unattended cart was accessible. Additionally, during a medication pass, an LPN removed medications from multi-dose pharmacy-prepared packages and left them on the cart while entering a resident's room, leaving the cart and medications unattended. Upon returning, a resident in a wheelchair was observed sitting by the medication cart. Facility policy states that only authorized personnel should have unsupervised access to medications and that medication carts must be locked or attended at all times. The LPN admitted to forgetting to lock the cart and leaving the keys in the lock due to being in a hurry, and was unaware that the multi-dose medication packages were left unsecured. The DON confirmed that medication carts should always be locked when unattended and that as-needed narcotic medications are stored in the medication carts on the halls.