Unsecured Medication Cart and Unattended Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely in locked compartments, as required by professional standards. During an observation, a lidocaine patch and two unidentifiable pills were found left unattended on top of an unlocked medication cart in a hallway accessible to residents. The medication cart was not under the direct observation of authorized staff at the time. Interviews with nursing staff and administration confirmed that the expectation is for medication carts to be locked and for medications not to be left unattended. Staff acknowledged the risk of residents accessing unsecured medications and described the proper procedures for medication administration and cart security. Despite these expectations, the incident occurred when a registered nurse left the cart unlocked and medications unattended while assisting another staff member. Other staff interviewed stated they would secure the cart and report any lapses if observed. The facility was unable to provide its Medication Storage/Labeling policy when requested. No medications were reported taken by residents, but the potential for harm existed due to the unsecured medications and unlocked cart.