Unlocked and Unattended Medication Carts on Two Units
Penalty
Summary
The deficiency involves failure to ensure that medications and biologicals were stored securely in locked compartments when unattended, as required by facility policy. On one occasion, a registered nurse on Unit B left a medication cart unlocked and unattended in the hallway while administering medications to a resident in their room. The nurse stated they believed they could see the cart from the doorway, but during medication administration they were behind the resident’s curtain, while the cart remained in the hallway. The facility’s medication administration policy dated 10/25/14 requires that during medication administration, the cart be kept closed and locked when out of sight of the medication nurse or aide, and that the cart be clearly visible and inaccessible to residents or others passing by. A second incident occurred on Unit C, where a medication cart assigned to an LPN was found unlocked and unattended. When the surveyor asked if the cart was locked, a CNA checked the cart, expressed surprise, and then locked it, confirming it had been left unlocked. Minutes later, when questioned by the surveyor, the LPN acknowledged that leaving the cart unlocked and unattended was an error. The facility’s storage of medications policy dated 10/25/14 states that medications and biologicals are to be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. The facility census at the time was 158 residents.
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