Medication Cart Left Unlocked and Unattended by Nurse
Penalty
Summary
A deficiency occurred when a nurse failed to secure the Hall 300 medication cart, leaving it unlocked and unattended for approximately five minutes in a hallway. During this time, the cart was positioned with its drawers facing the hallway and the lock mechanism disengaged, making medications accessible to unauthorized individuals. The nurse responsible for the cart admitted to being two rooms away and out of sight of the cart, acknowledging that she forgot to lock it before leaving. Observations revealed that the cart contained glucometers, over-the-counter medications, vitamins, minerals, eye drops, and a locked compartment with controlled substances and resident-specific medication packets. Interviews with the nurse, DON, and Administrator confirmed that facility policy requires medication carts to be locked and within the nurse's line of sight when not in use. The nurse stated she had been trained to keep the cart locked and recognized the risk of leaving it unsecured. The DON and Administrator reiterated expectations that all nursing staff are responsible for securing medication carts to prevent unauthorized access, in accordance with facility policy and procedures.