Medication Cart Left Unlocked and Unattended
Penalty
Summary
Facility staff failed to ensure that a medication cart was kept locked or under the direct observation of authorized staff in an area accessible to residents. During an observation tour, a medication cart was found unlocked outside the nursing station with no authorized staff in sight. The Unit Manager was unaware of the nurse assigned to the cart's whereabouts. Shortly after, the assigned LPN returned from outside the building, stating she had been making a phone call and acknowledged that leaving the cart unlocked and unattended was a mistake. The facility's policy requires that only licensed nurses, pharmacy personnel, or those lawfully authorized to administer medications have access to medications, and that medication carts must be locked when not attended by authorized personnel. Interviews with the Unit Manager and the LPN confirmed that the cart was left unattended and unlocked, contrary to facility policy. No further comments or concerns were voiced by facility leadership during the final interview.