Failure to Secure Medications and Treatment Carts
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were consistently secured and only accessible to authorized personnel, as required by facility policy. On multiple occasions, medication and treatment carts were observed unlocked and unattended in various areas, including the 300 Household, 700 Hall, and 900 Household. In one instance, a cup containing crushed medications mixed with a pudding-like substance, prepared for a resident with Parkinsonism and hypothyroidism, was left unattended on top of a medication cart. The nurse responsible for the cart was not present, and the cup was accessible to unauthorized staff. Staff later acknowledged that the medications should have been locked in the cart when unattended. Additionally, treatment carts containing insulin and medicated creams were found unlocked and unattended in both the 700 Hall and 300 Household. Staff admitted to leaving carts unlocked due to a lack of keys when agency staff were present. In another area, a medication cart was left unlocked, allowing staff to access its contents and use items from the cart without supervision. Facility leadership confirmed that all medications and carts should have been secured when not directly attended by authorized staff.