Medication Carts Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that medication carts were properly secured and locked, as required by policy and professional standards. During observations, three out of five medication carts were found unlocked and unattended in areas accessible to residents, staff, and visitors. On one occasion, a nurse left two medication carts unlocked and unattended while she entered a resident's room, leaving blister packs of medication on top of one cart with a resident sitting nearby. Another medication cart was observed unlocked while the responsible nurse was at the nurse's station, unaware that the surveyor was able to open drawers and take photographs. These carts contained prescription drugs, over-the-counter medications, vitamins, and, in some cases, narcotics stored in a locked box within the cart. Interviews with nursing staff, the DON, and the ADM confirmed that all had been trained on medication storage policies, which require medication carts to be locked whenever unattended. Staff acknowledged their responsibility for securing the carts and recognized the risks of leaving them unlocked. Despite this, the medication carts were left unsecured, and staff could not provide explanations for these lapses. Review of the facility's Medication Storage Policy further confirmed the requirement for secure storage of all medications.