Medication Cart Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that the west wing medication cart was left unlocked and unattended while unidentified residents were walking freely around it. The RN responsible for the cart returned after a short period and locked it, stating during an interview that she had forgotten to lock the cart. The RN acknowledged that leaving the cart unlocked could allow residents to take medications from it. Further interviews with the Assistant Director of Nursing (ADON) and the Administrator (ADM) confirmed that leaving medication carts unlocked could result in residents accessing and taking medications not prescribed to them. A review of the facility's medication administration policy, dated April 2019, indicated that medication carts are to be kept closed and locked when out of sight of the medication nurse or aide. The failure to follow this policy was directly observed and confirmed by staff interviews.