F0761

D

Unattended Medication Cart with Unsecured Medications and Needles Near Mobile Residents

Laplata, Maryland Survey Completed on 01-09-2026

Penalty

Fine: $17,215

Summary

Facility staff failed to keep medications and related supplies secured from residents when a medication cart was left unattended and accessible near the C/D unit nursing station. During a tour at 4:20 PM, a surveyor observed a medication cart pushed up against the nursing station with 2 insulin syringes, 2 hypodermic needles, and a Budesonide steroid inhaler on top. A ward clerk was seated at the desk and the C/D unit manager was in her office, but neither was assigned to or in charge of the medication cart. The Nurse Practice Educator (NPE) arrived shortly thereafter, independently observed the same unsecured items on the cart, and began looking for the nurse responsible for the cart.

The NPE was informed by staff at the nursing desk that the nurse assigned to the cart was in the bathroom. Moments later, a staff member exited a bathroom across from the nursing station and returned to the unattended medication cart, and it was verified that this was her cart and that she was an RN who had previously worked at the facility. During this time, two independently mobile residents were observed on the opposite side of the nursing station, in an area where they would not be visible to staff if they approached the cart. Review of the medical record for one of these residents showed a diagnosis of Alzheimer's disease and a care plan for eating and chewing inanimate objects. The unsecured medications and administration instruments on the unattended cart in the vicinity of these vulnerable residents were reported to the DON and discussed again with the facility at exit.