Unattended Unlocked Medication Cart
Penalty
Summary
A medication aide left an unlocked medication cart unattended near a TV room and dining area where several residents were present, including residents who were propelling themselves around the area. The cart contained medications for all residents in the 200 hall. The medication aide acknowledged that the cart should have been locked when not in use or out of sight but stated she forgot to lock it when she went to the restroom. Observations confirmed that the cart was left unlocked and unattended, and this was witnessed by a licensed vocational nurse (LVN), who stated that the cart should always be locked for safety to prevent residents from accessing medications. Interviews with the LVN and the Director of Nursing (DON) confirmed that facility policy requires medication carts to be locked when not in use to prevent unauthorized access, especially given the presence of residents with dementia. The facility's medication storage policy also specifies that compartments containing medications must be locked when not in use. The failure to secure the medication cart was identified through observation, record review, and staff interviews.