Unsecured Medication Carts with Narcotics Left Unattended
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required, as observed with two medication carts on the 100 Hall. On two separate occasions, medication carts assigned to two different LVNs were found unlocked and unattended in the hallway, with the keys left on top of the carts. Both carts contained medications, including narcotics, and were accessible to residents who were observed walking by at the time. The locks on the carts were disengaged, allowing all drawers to be opened and accessed. Interviews with the LVNs responsible for the carts confirmed that they had forgotten to lock the carts and secure the keys before leaving the area. Both nurses acknowledged that it was their responsibility to keep the carts locked and the keys secured when not in use. The ADON and Administrator also confirmed that it was the nurse's responsibility to maintain the security of the medication carts and keys, and that staff had been previously in-serviced on this requirement. Review of the facility's policy indicated that medication carts must be locked when unattended and that controlled medications must be stored separately in double-locked compartments.