Unlocked Medication Cart Left Unattended With Medications Accessible
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications on one of four medication carts (MC #1) were properly secured and accessible only to authorized personnel. During an observation at the nurses’ station, surveyors found MC #1 unlocked and unattended while a nurse sat inside the nurses’ station out of view of the cart, with residents and staff walking by. The unlocked cart contained residents’ prescribed creams, prescribed drugs, over-the-counter medications, narcotics, catheters, and breathing treatment medications. The facility’s written policy on storage of medications, dated 4/2019, stated that drugs and biologicals must be stored in locked compartments and that unlocked medication carts are not to be left unattended. In interviews, LVN A stated he had been trained on medication storage and acknowledged that the policy required staff to lock the medication cart anytime they walked away, even briefly, and that the nurse assigned to the cart was responsible for locking it, although any staff member who noticed an unlocked cart could lock it. He acknowledged that a resident might get into an unlocked cart and did not know why he had left MC #1 unlocked. The DON and the ADM both confirmed they had been trained on medication storage and described the same policy expectations that medication carts must always be locked when not in use, with the assigned nurse or medication aide responsible for securing the cart. They each reported that nursing management, including the DON and ADM, monitored compliance by walking the halls and observing carts, and neither could explain why LVN A did not lock the cart at the time of the observation.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.