Unlocked and Unattended Medication and Treatment Carts
Penalty
Summary
The deficiency involves the facility’s failure to keep medication and treatment carts locked when not under the direct observation of the assigned nurse, contrary to facility policy requiring all drugs and biologicals to be stored in locked compartments and secured when not in use. Surveyors observed an unlocked and unattended medication cart on one hall early in the morning, with the assigned LPN acknowledging that the cart should have been locked, stocked, and secured when she left it to go down another hall approximately 64 feet away. Additional observations showed two medication carts and a treatment cart unlocked and unattended near the nurses’ station for two halls, with one cart’s narcotic box door open (though the narcotic box itself was locked). The drawers of these carts contained OTC medications, insulin pens and vials, inhalers, nebulizer medications, and multiple resident bubble packs of prescription drugs including anticoagulants, antipsychotics, antihypertensives, analgesics, diuretics, and potassium chloride. Surveyors further observed another unlocked and unattended medication cart on a different hall, and staff interviews confirmed that nurses had been off the floor and out of sight of their assigned carts for approximately 10–15 minutes while the carts remained unlocked. One agency LPN stated she and another nurse were assigned to the treatment cart and that the carts should not have been left unlocked, acknowledging she had been trained by both the agency and the facility on the importance of locking carts when out of sight. Later that morning, another medication cart on a hall was found unlocked while the assigned LPN was approximately 35 feet away in a resident’s room; the LPN stated she left the cart unlocked to respond to a yelling resident but recognized it should have been locked when not in her line of sight. The DON and the Administrator both stated their expectation that medication and treatment carts be locked when nurses are away and out of sight of the carts, confirming that the observed practices did not meet facility expectations or policy.
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