Failure to Secure Treatment Cart as Required
Penalty
Summary
The facility failed to ensure that treatment cart #1 was locked and secured in accordance with professional standards and facility policy. Multiple observations were made on different dates and times where treatment cart #1 was found unlocked and unattended in various locations near the nurse's station and on Hall A. Nursing staff, including LPNs and an RN, were observed either away from the cart or unable to see it while it remained unlocked. The facility's policy required medication and treatment carts to be locked at all times when not in use or out of the nurse's view, but this was not followed. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was for treatment carts to be locked and supervised at all times. Staff admitted to leaving the cart unlocked and unattended, acknowledging that it was out of their sight during these periods. The facility had 50 residents at the time, and the unsecured cart was accessible in common areas without supervision, contrary to both facility policy and accepted professional principles.