Unattended and Unlocked Medication Cart Left Accessible in Resident Hall
Penalty
Summary
A deficiency occurred when a medication cart was left unattended and unlocked in the doorway of a resident room on Hall 500. The cart's lock was visibly disengaged, and no staff were present in the immediate area, while two residents were in their room watching TV. The incident was observed by a surveyor, who noted that the cart was accessible to anyone passing by. The nurse responsible for the cart, an LVN, returned to the cart a few minutes later and acknowledged that she had left it unlocked while attempting to speak with a doctor. She confirmed that the cart could have been accessed by unauthorized individuals during her absence and admitted that it should have been locked. The facility's policy requires all drugs and biologicals to be stored in locked compartments when not in use, and medication carts are not to be left unattended if open or accessible. The LVN stated she had just administered diabetic medication to a resident prior to leaving the cart. The incident was confirmed through observation, staff interviews, and review of facility policy and employee records. The administrator and DON were made aware of the incident and confirmed that leaving medication carts unlocked is against facility policy.