Unattended Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments when not in use, as required by facility policy and professional standards. The written policy on medication storage stated that only licensed nurses, pharmacy staff, and other authorized personnel may access medication carts, and that medication rooms, cabinets, and supplies must remain locked when not in use or attended by authorized staff. During observation, a medication cart was seen positioned between resident rooms, unlocked and unattended for approximately four minutes while several visitors and staff walked past it in the hallway. The LPN responsible for the cart later returned, locked the cart, and acknowledged having left it unlocked and unattended despite knowing it should be locked when not in direct line of sight. The DON confirmed that the facility’s expectation is that nurses keep medication carts locked when they are not directly observing them. No specific residents, their medical histories, or conditions at the time of the deficiency were identified in the report, and the deficiency centered on the unsecured medication cart and staff noncompliance with the established medication storage policy.
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