Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart (Cart Hall D) was observed left unlocked and unattended for five minutes while not in use. During this time, three CNAs and residents were present in the hallway within arm's reach of the cart, and the responsible nurse was not in sight. The cart contained various medications, including controlled substances, anti-depressants, blood thinners, anti-diabetics, anti-psychotics, and other medical supplies. The Assistant Director of Nursing (ADON) confirmed that the cart should not have been left unlocked and stated that the responsible nurse, LVN A, was distracted by a family member and followed them down the hall, leaving the cart unsecured. LVN A stated she did not believe she had left the cart unlocked, but acknowledged that leaving medication carts unsecured could negatively affect residents. The Director of Nursing (DON) stated her expectation that all medication carts be locked when out of the nurse's direct vision and confirmed that she periodically checks the carts throughout the day. Facility policy requires that medication carts be locked when not attended by authorized personnel. The failure to secure the medication cart was attributed to poor judgment on the part of the nurse.