Unlocked Medication Cart Left Accessible in Nurse Station Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were stored in locked compartments when not in use. During observation, surveyors found Medication Cart A unlocked in front of a nurse’s desk, with its back against the nurse’s station. The cart’s locking mechanism was protruding outward, and the drawers could be easily opened, allowing access to the medications inside. Photographs of the unlocked cart were taken by the state surveyor. In interviews, the RN assigned to the cart stated she believed she had locked it before entering the nurse’s station and acknowledged she had the only set of keys for that cart. She confirmed she had been in-serviced previously on the requirement to lock medication carts and was aware the cart should have been locked. The Administrator and the DON both stated their expectation that all medication carts be locked when nurses were not administering medications and confirmed that staff had been in-serviced on securing the carts, though neither could recall the specific in-service dates. The facility’s Administering Medications Policy, dated April 2019, states that during medication administration the cart must be kept closed and locked when out of sight of the medication nurse or aide, with no medications kept on top of the cart and all outward sides inaccessible to others.
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