Failure to Secure Medication Cart and Restrict Access to Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to the keys for medication storage. Specifically, Medication Cart #1 was observed unlocked on two separate occasions in front of the nurses' station. During the first observation, a registered nurse (RN) was present behind the nurses' station but did not realize the cart was unlocked. The RN acknowledged that all medication carts were supposed to be locked except when a nurse was obtaining medications and confirmed she had received in-service training on this requirement, though she could not recall when. On the second occasion, the same medication cart was found unlocked with no nurse present in the area. The RN returned approximately ten minutes later and admitted she had walked away to assist a resident, mistakenly believing she had locked the cart. She acknowledged this was the second time that day she had forgotten to lock the cart and could not provide an explanation for her oversight. The Assistant Director of Nursing (ADON) confirmed that staff had been in-serviced on securing medication carts but could not recall the last in-service date. Facility policy requires that medications and biologicals be stored safely and securely, accessible only to licensed nursing personnel or staff authorized to administer medications.