Failure to Secure Medications in Unattended Treatment Carts
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were secured in accordance with professional standards. On two separate occasions, treatment carts containing medications such as insulin, Narcan, lidocaine patches, and various antiseptics were found unlocked and unattended. On the second floor, a treatment cart was left unlocked next to the nurses' station while staff were present but not attending to the cart. The key to the cart was found in an open compartment, and staff admitted to leaving it there for easy access, contrary to facility protocol. The cart remained unlocked and unattended for several minutes, with staff unable to provide a reason for this lapse. A similar incident occurred on the first floor, where another treatment cart was observed unlocked and unattended around the corner from the nurses' desk. Staff walked past the cart without securing it, and a CNA accessed supplies from the cart. When questioned, staff acknowledged that the cart should not have been left unlocked and stated it was an oversight. The Director of Nursing confirmed that facility policy required carts to be locked when out of sight and that keys should be kept on the nurse, not left in or near the cart.