Unlocked Medication Cart Left Unattended in Hallway Near Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were stored in locked compartments and accessible only to authorized personnel, as required by facility policy and State and Federal laws. On the morning of 01/13/2026 at 8:35 a.m., surveyors observed Medication Cart #1 unlocked and positioned against a wall near the entrance to the dining room, with the drawers facing the hallway. The locking mechanism was protruding outward, and the State Surveyor was able to open the drawers and take photographs. At that time, the RN responsible for the cart (RN A) was in the dining room passing out meal trays to residents and was unable to view or monitor the cart. Visitors were later observed walking down the hall near the still-unlocked cart. During interview, RN A stated she believed she had locked the cart before entering the dining room to assist with breakfast and expressed surprise that it was unlocked. She confirmed she had the only set of keys for that cart and acknowledged that residents and visitors had access to the medications when the cart was left unlocked. RN A reported she had been in-serviced on the requirement to keep medication carts locked when not in use but could not recall the date of the in-service. In a separate interview, the DON stated that medication carts were expected to be locked unless the nurse was standing at the cart administering medications, with no exceptions, and confirmed that staff had been in-serviced on this expectation, though she also could not recall the date. Review of the facility’s Medication Labeling and Storage policy, dated 2001, documented that all medications and biologicals must be stored in locked compartments, with only authorized personnel having access to keys, and that carts used to transport medications must not be left unattended if open or otherwise available to others.
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