Unsecured Medication Keys Left Accessible During Nurse’s Lunch Break
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored securely and in accordance with its own policy and procedure. The facility’s policy titled “Medication Cart,” revised 8/1/24, stated that only pharmacists and licensed nurses would have access to the medication cart and that if a nurse left the floor for any reason, they must turn over the keys to another nurse. Contrary to this policy, on 12/5/25, Licensed Nurse (LN) A left the medication keys in an unlocked area at the nurse’s station when leaving the facility for a lunch break, rather than handing them to another nurse. During interviews, the Nurse Manager reported hearing that LN A left for a lunch break and threw the medication keys on the counter at the nurse’s station, prompting a CNA to call the Nurse Manager. CNA B confirmed that LN A left the facility for lunch and left the medication keys unsecured at the nurse’s station, and that Resident 1 was awake and aware the nurse had left. Resident 1 confirmed witnessing LN A place the medication keys at the nurse’s station before leaving. The DON verified that when an LN leaves for a lunch break, they are expected to hand over their medication keys to another LN, and confirmed that on the date in question, LN A placed the keys at the nurse’s station where they were available for anyone to use. LN A acknowledged leaving the keys in an unlocked drawer at the nurse’s station, with two CNAs and Resident 1 present at the time, making medications accessible to facility staff and residents and having the potential to cause a decline in resident health status.
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