Unattended, Unlocked Medication Cart on 400 Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored and secured in accordance with professional standards for one of five medication carts, specifically the cart on the 400 hallway. During an observation at 6:07 PM, the 400 Hall nurse’s medication cart was found unlocked and unattended while positioned against the nurse’s station. When the surveyor notified GVN A, who was responsible for that cart, he then locked it. GVN A stated he was expected to lock the medication cart whenever he walked away from it and confirmed that the cart contained medications for residents on the 400 hallway. In an interview, GVN A acknowledged responsibility for the cart and recognized that if it was left unlocked, a resident could open a drawer and take medication not prescribed for them. In a separate interview, the DON stated that multiple staff, including the DON and ADON, were responsible for ensuring medication carts were locked and confirmed the expectation that staff lock the cart whenever they walk away from it. The DON stated that if the cart was left unlocked, a resident or visitor could grab medication from the cart and it could harm them. Review of the facility’s policy “Medication Carts and Supplies for Administering Meds,” dated 10/1/2019, showed that the medication cart is required to be locked at all times when not in use.
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