Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on Hall D was observed to be left unlocked and unattended for approximately five minutes while not in use. During this time, three CNAs and residents were present in the hallway within arm's reach of the cart, and the responsible nurse was not in sight. The cart contained various medications, including anti-depressants, blood thinners, anti-hypertensives, diuretics, insulin pens, anti-psychotics, anti-anxiety medications, creams, syringes, liquid medications, alcohol pads, and over-the-counter medications. The Assistant Director of Nursing (ADON) confirmed that the cart should not have been left unlocked and unattended, and the Director of Nursing (DON) stated that her expectation is for all medication carts to be locked when out of direct vision of the nurse. The nurse responsible for the cart reported being distracted by an upset family member and followed them down the hall, leaving the cart unsecured. The facility's policy requires that medication carts be locked when not attended by authorized personnel. The DON acknowledged that the failure occurred due to poor judgment on the nurse's part and confirmed that she periodically checks to ensure medication carts are locked throughout the day.