Unlocked Carts and Unattended Prepoured Medications Left in Common Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards. Over multiple days, a treatment cart located near the front entrance was observed unlocked and unmonitored by nursing staff for extended periods. The contents of this treatment cart included wound care supplies and prescription medications, yet it remained accessible when no nurse was present. The facility was unable to provide a medication storage policy when requested during the survey. On another occasion, a medication cart was observed unlocked and unattended by the assigned RN. On top of this cart, surveyors observed a prefilled insulin syringe and several paper medication cups labeled with different residents’ names, each containing medications. These cups were stacked so that the bottom of one cup was in contact with another resident’s medications, and there was also a plastic medication cup containing an unknown medication at the top of the stack. These medications were left on the cart in a common area without the medication nurse in sight, and the RN later stated she had left the cart to go into the supply room. Staff interviews confirmed that both treatment and medication carts were expected to be locked when not being accessed and that prepouring medications was not allowed, but these expectations were not followed in the observed instances.
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