Unlocked and Unattended Medication Cart Left Accessible by RN
Penalty
Summary
The deficiency involves failure to ensure medications were securely stored on one of two medication carts when a nurse left the cart unlocked and unattended. On 1/16/2026 at 8:16 AM, observation of the short hall medication cart showed it was unlocked and unattended after RN DD had unlocked the cart, opened the computer screen, and pulled up Resident 5’s list of medications. RN DD then walked away from the cart to throw something away, leaving the cart unlocked with the computer screen open, and returned at 8:17 AM to remove Resident 5’s medication from the cart. In an interview at 8:21 AM, RN DD confirmed she had walked away from the unlocked cart and stated she thought it was acceptable because the surveyor was standing nearby, acknowledging she should have locked the cart and closed the computer screen before leaving. In a separate interview at 10:29 AM, the DON stated it was her expectation that nursing staff lock the medication cart before walking away from it. This deficient practice created the potential for unauthorized entry and diversion of medications, as documented in the survey findings.
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