Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were securely stored and medication carts were locked in accordance with facility policy and professional standards. The facility’s Medication Storage policy, last approved in December 2025, requires all medications and biologicals, including treatment items, to be securely stored in a locked cabinet/cart or locked medication room that is inaccessible to residents and visitors. The Medication Administration Policy, last approved in October 2024, further specifies that medication storage areas, including medication carts, must be locked when not in use by authorized personnel, and that any other individual needing access must be supervised by an authorized person. On the date of the survey, an RN left a medication cart unlocked in the hallway across from a resident room on a hall where 23 residents reside. The RN left the cart to check a resident’s blood sugar, leaving medications accessible to residents, staff, and visitors. When questioned, the RN initially stated the cart had been locked and that they always lock the medication cart, but when asked why keys were not used to reopen the cart upon returning to obtain insulin for the resident, the RN became flustered and acknowledged making a mistake regarding the cart being unlocked. The DON confirmed that medication carts should always be locked when the nurse leaves the cart and that nothing, including medications, needles, or keys, should be accessible on top of the cart.
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