Unlocked medication cart allowed resident access to another resident’s medications
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments when a medication cart (Sapphire Cart) was left unlocked, allowing a resident to access another resident's medications. A facility reported incident indicated that at 9:30 AM, the resident was observed with three pill packets and several loose pills in their left pant pocket. When the medications were reconciled, all were accounted for except one dose of Namenda, a medication used to treat moderate to severe dementia, which was never recovered. The resident involved had been admitted for long-term care with a medical history including diabetes, urinary retention, and falls related to muscle weakness. They were independent in a wheelchair for short distances, alert and oriented to person and place, their own responsible party, and had a BIMS score of 8/15 indicating moderate cognitive impairment. In a telephone interview, the RN assigned to the Sapphire Cart acknowledged and accepted full responsibility for leaving the cart unlocked, explaining they had been very busy, walked away from the cart to assist another resident with breakfast, and did not lock it. The RN reported being informed by a CNA that the resident had pill packets hanging from their pant pocket; when confronted, the resident stated another resident had the medications, took them from them, and that they were going to tell staff.
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