Unattended Medications Left on Medication Cart
Penalty
Summary
A medication aide (MA) failed to properly secure medications during a medication pass on Hall 600. The aide left a blister pack containing 10 white oval pills and a souffle cup with 4 assorted pills on top of a locked medication cart while stepping away to wash hands and later to retrieve additional medication supplies. During these times, the medications were unattended and out of the aide's line of sight, with no staff or residents immediately present at first, but later a resident in a wheelchair was observed near the unattended cart. Multiple staff members also walked past the unattended cart during this period. The aide acknowledged during interviews that the medications should not have been left unattended on top of the cart and confirmed that she had been trained on proper medication storage and cart security. She explained that she left the medications out because she had a question about them and did not want to forget, but admitted this was not in accordance with her training. The medications included allopurinol tablets intended for a single resident, and the aide recognized the potential for someone else to take the medication while it was left unsecured. Facility policy, as reviewed, requires that medication carts be locked when not in use and that medications remain in the clear view and reach of the person administering them. Both the DON and the Administrator confirmed in interviews that staff are expected to maintain visual contact with medication carts at all times and never leave medications unattended on top of the cart. The incident was observed and confirmed by surveyors, and the facility's policies were found to be consistent with accepted professional principles for medication security.