Medication Cart Left Unlocked and Unattended
Penalty
Summary
A nurse medication cart was observed parked outside the nurse's station, unlocked and unattended, with drawers containing medications accessible and facing the hallway. A resident in a wheelchair was sitting approximately ten steps from the open cart. Multiple staff interviews confirmed that the cart should have been locked when not in use, and that it was not clear who was responsible for the cart at the time it was left unattended. The facility's policy requires all drugs and biologicals to be stored in locked compartments when not in use, and for carts to not be left unattended if open or accessible. Further interviews revealed that the LVN responsible for the cart left it unlocked while going to the restroom, acknowledging that the cart should have been secured before leaving it unattended. Staff, including the ADON, DON, and Administrator, all stated that the expectation is for all medication carts to be locked when not in use to prevent unauthorized access. The facility's policy, dated December 2024, reiterates the requirement for all compartments containing drugs and biologicals to be locked when not in use.