Unattended Pre-Poured Medications Left on Medication Cart
Penalty
Summary
A medication cup containing pre-poured medications for one resident was left unsecured on top of a medication cart in the hallway when the charge nurse, an LPN, walked away to assist another resident with putting on shoes. The medication cart was left unattended and not within the nurse's line of sight, while several residents were observed sitting nearby in the hallway. The incident was observed during a facility tour with the Assistant Director of Nursing (ADON), who acknowledged the presence of the unattended medication cup on the cart. Review of the medication administration record confirmed that the cup contained multiple medications, including citalopram, empaglifozin, folic acid, loratadine, Norvasc, risperidone, apixaban, Entresto, metformin, Senokot S, and vitamin B12, all intended for a specific resident. Both the LPN and the ADON confirmed in interviews that medications should not be left unattended or unsecured, and facility policy requires medications to be kept secured in a locked area or under visible control at all times.