Unsecured Medication Carts and Unattended Medications on Secure Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments and kept secured when not in use. During an observation on the secure unit, two medication carts (Medication Carts L and R), both assigned to a single certified medication aide responsible for medication administration on that unit, were found unsecured and unsupervised for four minutes. Medication Cart R was positioned against the wall with its drawers facing the hallway, the lock mechanism extended, and the keys left in place, indicating it was unlocked. Medication Cart L was also against the wall with its second drawer open. On top of Medication Cart L, surveyors observed a medication cup containing a white pill, and another medication cup containing white crushed specks mixed with a brown substance and a wooden spoon, all left unattended. Inside Drawer #1 of both carts were OTC aspirin, vitamins, minerals, and eye drops, and Drawer #2 contained multiple residents’ individual bubble-blister medication packets. At the time, 13 residents resided on the secure unit, with four residents and one visitor present in the hallway approximately 15 feet from the carts. Further observation showed that the certified medication aide responsible for both carts was in the employee break room, approximately 75 feet away from the unlocked carts, during the time they were left unattended. In an interview, the medication aide acknowledged she was in charge of the carts, admitted she had left them unlocked with the keys in the lock on one cart, and stated she had gone to the break room to get a drink of water while medications were set up on top of the cart. She also reported that she had been in-serviced on the requirement to keep the medication cart locked at all times when not in use and recognized that anyone on the secure unit could access the medications. The DON and the Administrator both stated their expectation that nursing staff, including medication aides, follow facility policy requiring medication carts to be locked whenever staff walk away or turn their back, and confirmed that staff are trained during orientation, annually, and as needed on medication administration and securing medications. The facility’s written policy, “Security of Medication Cart,” states that the medication cart shall be secured during medication passes.
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