Medication Cart Keys Left Unsecured During Nurse Absence
Penalty
Summary
Facility staff failed to store medications securely on one of three medication carts on the second floor. A registered nurse, who was unfamiliar with the medication cart and only worked a few shifts per month, was observed searching for medications and, upon needing to retrieve medications from another floor, locked the cart but left the keys hidden under a towel on top of the cart. The nurse left the cart unattended in the hallway while retrieving medications from the emergency supply on another floor, returning several minutes later to retrieve the keys and continue medication administration. This sequence occurred multiple times, with the keys repeatedly left on top of the cart under a towel while the nurse was away. During one of these absences, two residents walked by the unattended medication cart. The nurse later acknowledged that the cart was not fully secure because the keys had been left on top of it. Interviews with a unit manager confirmed that facility policy requires nurses to keep medication cart keys in their pocket when leaving the cart, and the facility's written policy mandates that medication storage areas be locked and not left unattended if accessible to others. The administrator, director of nursing, and regional director of clinical operations were informed of these concerns.