Unlocked Medication Carts During Med Pass
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security when two medication carts were found unlocked during observations. On the 100 hall, the respiratory therapist’s medication cart was observed unlocked at 7:18 a.m. The respiratory therapist stated in an interview that she had been assisting a resident with medications and forgot to lock the cart, acknowledging that anyone could come and take the medications. The facility’s Medication Storage policy, revised 05/2023, requires that all drugs and biologicals be stored in locked compartments and that, during a medication pass, medications must be under the direct observation of the person administering them or locked in the medication storage area or cart. On the 300 hall, a nurse’s medication cart was observed unlocked at 7:24 a.m. The LVN assigned to that cart stated in an interview that she heard a resident yelling for help and went to assist, leaving the cart unlocked. She stated that the risk of leaving the cart unlocked was that a resident could possibly get into the cart and take medication. In interviews, the DON stated that the expectation is for medication carts to be locked before staff walk away, and the risk of unlocked carts is that medication could be taken out and used for alternative purposes. The administrator stated that, for safety and security, they conduct purposeful rounding to double-check that medication carts are locked when staff walk away and that her role is to ensure systems are completed within local and state compliance and to address deficient practices. The report notes that the risk of medication carts being unlocked is medication error and potential harm to residents.
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