Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two of three medication carts (MC #1 and TC #2) were left unlocked and unattended near the nurses' station. MC #1 contained residents' prescription drugs, over-the-counter medications, and narcotics secured in a locked box within the cart, while TC #2 contained residents' prescription creams. At the time of observation, no nurses or staff were present in the vicinity of either cart. Interviews with nursing staff, the DON, and the administrator confirmed that facility policy requires medication carts to be locked at all times when not in use and that only authorized personnel should have access. Staff acknowledged awareness of the policy and admitted the carts should have been locked when unattended. The facility's Medication Labeling and Storage Policy, reviewed by surveyors, states that all medications and biologicals must be stored in locked compartments and only authorized personnel may access them. Despite this, both nursing and administrative staff could not provide an explanation for why the carts were left unlocked. The staff described monitoring practices that rely on observation by nurses, administrative staff, and peer-to-peer checks, but these measures failed to prevent the carts from being left unsecured and accessible to unauthorized individuals.