Unattended Medication Cart With Accessible Medications on Resident Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored properly and in accordance with its own Medication Labeling and Storage policy on the West unit. On 2/25/26 at 9:43 a.m., a surveyor observed an unattended medication cart located outside a resident room on the named unit. On top of the cart, there was a medication cup containing an unknown red liquid and a clear plastic cup containing plastic sleeves used for crushing medications, with visible medication residue inside the sleeves. The medication cart was unattended during this time. During the observation, Resident #3 was seen foot-propelling in his/her wheelchair in the hallway near the unattended medication cart. At 9:50 a.m., CNA-M #1 returned to the cart and, during an interview, stated that the plastic sleeves were trash containing residue from medications she had crushed for a resident and that the red liquid in the medication cup was Robitussin she had poured for a resident. CNA-M #1 acknowledged she should have placed the medication in a locked drawer before leaving the cart unattended. The facility’s written policy, revised 3/2025, requires all medications and biologicals to be stored in locked compartments and specifies that carts used to transport medications are not to be left unattended if open or otherwise potentially available to others.
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