Unattended and Unlocked Medication Cart with Accessible Drugs and Items
Penalty
Summary
During a medication storage inspection, surveyors observed that medication cart #1 was left unlocked and unattended outside the nurse's station, with residents and staff in close proximity and out of staff eyesight. The cart had unlocked drawers facing outward and contained various items including a butter knife, nail clippers, mouth wash, an unopened petrolatum dressing, glucometers, lancets, lab draw kits with needles, hand sanitizer, zinc oxide creams, moisture barrier creams, and several over-the-counter (OTC) medications such as Milk of Magnesia, cough suppressant, fish oil, gas relief tablets, B-Vitamins, Colace, Vitamin D, acid reducers, melatonin, and senna tablets. AA batteries were also found in one of the drawers. The cart was identified as previously used for isolation during COVID-19 but was no longer in use for that purpose. Interviews with the DON, LVN, and ADMN confirmed that the cart should have been locked when not in use and that staff were responsible for monitoring and securing it. The DON acknowledged that residents could have accessed the medications and items on the cart, potentially leading to harm. The ADMN stated that the responsibility for ensuring medication carts are locked ultimately rested with him and that the failure to secure the cart was due to staff being too busy to lock it after use. Facility policy reviewed by surveyors required all medications and biologicals to be stored in locked compartments, with access limited to authorized personnel.