Medication Cart Left Unlocked and Unattended by Nurse
Penalty
Summary
A nurse medication cart on Hall 100 was observed to be left unlocked and unattended at the main nurse station for six minutes, with the drawers facing the hallway and the lock mechanism indicating it was unsecured. During this time, the nurse responsible for the cart, LVN E, was in a resident's room with the door closed and out of sight of the cart. The cart contained various medications, including over-the-counter aspirin, vitamins, minerals, eye drops, accu-check strips, glucometers, and a locked compartment with controlled substances and multiple residents' medication bubble-blister packets. The unlocked cart was accessible to unauthorized individuals and residents passing by. LVN E acknowledged responsibility for the cart and admitted to forgetting to lock it before leaving to speak with a resident. She confirmed awareness of the policy requiring the cart to be locked at all times when not in use and stated she had received in-service training on this requirement earlier in the year. The Director of Nursing and the Administrator both confirmed the facility's policy and expectation that medication carts be locked and secured when not in use, and that only authorized personnel should have access to medications. Facility policy documents reviewed also specified that all drugs and biologicals must be stored in locked compartments and that medication carts are not to be left unlocked and unattended.