Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medication cart (MC #1) was observed unlocked and unattended on the 100-hall, containing residents' prescription drugs, over-the-counter medications, and narcotics secured in a locked box within the cart. During the observation, a resident was seen walking past the unlocked cart, and the assigned RN was not present on the hall. Interviews with the RN, DON, and ADM confirmed that facility policy requires medication carts to be locked whenever out of staff sight, and that the person assigned to the cart is responsible for ensuring it is locked. The RN stated she left the cart unlocked because she responded to a resident emergency in the dining room and forgot to lock the cart while retrieving her blood pressure cuff. The DON and ADM both acknowledged awareness of the policy and confirmed that staff and managers are expected to monitor medication cart security through observation. The facility's Medication Labeling and Storage Policy specifies that all drugs and biologicals must be stored in locked compartments when not in use. The incident was attributed to the RN's response to an emergency situation, during which the medication cart was left unsecured and unattended, contrary to facility policy.