Unlocked and Unattended Medication Cart at Nurse’s Station
Penalty
Summary
The deficiency involves the facility’s failure to keep a second-floor medication cart locked and secured when unattended. During an observation and interview on 01/13/2026 at 2:30 p.m., the surveyor found the medication cart at the second-floor nurse’s station unlocked and unattended, and was able to open the top drawer, which contained medications and biologicals for residents. A security camera review from 2:29:04 p.m. confirmed that the cart was unlocked when the surveyor opened the drawer. At 2:29:07 p.m., the MDS Coordinator approached, closed the drawer, locked the cart, and then walked behind the nurse’s station. At 2:30:05 p.m., LVN A approached the cart, pushed on the lock, and stated it was locked, and during interview at 2:35 p.m., LVN A denied that the cart had been observed unlocked, though acknowledged that a resident could open an unlocked cart. In contrast, during an interview at 3:10 p.m., the MDS Coordinator stated she locked the cart because it was unlocked, unattended, and could be opened by someone other than the nurse responsible for it, and that a medication cart should be locked when the responsible person is not standing in front of it. In separate interviews, the Administrator and DON both stated the expectation that medication carts are to be locked when not in use or whenever the nurse turns away from the cart, and that residents could access medications if the cart is left unlocked. A review of the facility’s “Storage of Medications” policy (revision date 08-2020) showed that medications and biologicals are to be stored safely and securely, and that only licensed nurses, pharmacy personnel, and others lawfully authorized to administer medications may access medications, with medication carts and supplies to be locked when not attended by authorized personnel. The observed unlocked and unattended medication cart was therefore inconsistent with the facility’s stated policy and expectations.
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