Unlocked and Unattended Medication Cart with Keys Left in Lock
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments with access limited to authorized personnel. During an observation on Hall C, a medication cart was found unlocked and unattended in the middle of the hall between specified rooms, with the keys still in the lock mechanism. An MDS nurse approached the unattended cart, pushed in the lock mechanism to secure it, and removed the keys, stating that the cart should have been locked and that the nurse should not have left it unlocked when unattended. She identified the cart as belonging to an LVN assigned to Hall C. In a subsequent interview, the LVN acknowledged that the unattended, unlocked cart belonged to her and that it was a nurse cart. She reported that she had just finished cleaning the cart and had quickly gone into the medication room to get blood sugar strips, forgetting both to lock the cart and to take the keys with her. She stated that it was important to keep the medication cart locked and the keys safely removed and in the nurse’s possession, and she recognized that the risk was medication safety related to residents or others obtaining narcotic medications. The facility’s policy on Medication Storage, revised 01/2026, requires that medication carts remain locked and secured unless under direct and continuous supervision of authorized personnel, and that keys must always remain on the authorized staff member and not be left in or on the cart or unattended.
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