Medication Carts Found Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for medication carts. During observations, three out of four medication carts were found unlocked and unattended, with residents and staff in close proximity. Specifically, medication carts #1 and #2 were observed unlocked in the early morning with medication drawers facing outward, containing various prescription and over-the-counter medications. The responsible RN admitted to intentionally leaving the carts unlocked in anticipation of the day shift. Later, medication cart #3 was also found unlocked and unattended, with the responsible RN stating she believed she had visual contact with the cart, but her back was turned at the time of observation. She was unaware of the specific medications or the residents for whom they were intended. Interviews with facility leadership, including the administrator and assistant director of nursing, confirmed that all medication carts should have been locked when not in use and that only authorized personnel should have access. Both leaders acknowledged that the failure was due to staff being too busy or inattentive to proper medication storage protocols. Facility policy reviewed indicated that medications must be stored securely and only accessible to licensed or authorized personnel, with medication carts locked when not attended.