Unattended, Unlocked Medication Cart Accessible to Residents
Penalty
Summary
Surveyors identified a deficiency related to medication security when medication cart #1 (MC #1) was observed unattended and unlocked in the main lobby area, with a resident present nearby. A subsequent observation showed staff members walking past the still-unlocked cart. The facility’s own policy, titled “Security of Medication Cart” and dated April 2007, states that medication carts must be securely locked at all times when out of the nurse’s view and locked and parked at the nurses’ station when not in use. The report notes that this failure could place residents at risk of overdose, hospitalization, and pain. Multiple staff interviews confirmed that they had been trained to keep medication carts locked and understood the requirement to secure them when not in use or when out of their direct view. RN A, who had worked at the facility for 5 years, acknowledged she left MC #1 unlocked due to an oversight and stated that residents could access medications if the cart was left unlocked. LVN B, CNAs C and D, the DON, and the Administrator each stated that the assigned nurse or medication aide is responsible for locking the cart and that the cart should remain secured when not actively in use. They also stated that residents could access medications from an unlocked cart, with potential for harm, including poisoning or death, if medications were ingested.
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