Unlocked, Unattended Treatment Cart with Medications Accessible in Resident Area
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that all drugs and biologicals were stored in locked compartments under proper controls and that only authorized personnel had access to the keys for a treatment cart. During an observation at 6:59 a.m., Treatment Cart #1 was found unlocked and unattended, with a bottle of betadine in a basket affixed to the side of the cart. There were no staff present at the nurses’ station, and residents were moving about the facility at the time. The Human Resources staff member present acknowledged that the cart was not supposed to be unlocked and stated he did not know who was responsible for the cart because he worked in Human Resources, but indicated that the Treatment Nurse had just arrived. In a subsequent interview, the Treatment Nurse stated that the night nurse was responsible for the treatment cart, as that nurse worked the night shift and would have provided treatments for residents. An interview with the DON confirmed that her expectation was that medication and treatment carts be locked when not in use and unattended, and that medications and treatments must be secured and not left outside or on top of the cart. The DON stated that the facility had mobile residents and that any staff member could lock a cart if they passed by it, but the nurse assigned to the cart was responsible for ensuring it was locked when not in use. Review of the facility’s “Medication Cart Use and Storage” policy, revised January 2023, showed that licensed nurses and CMAs were responsible disciplines and that the medication cart and its storage bins should be kept closed, secured, and/or in the line of sight when not in use.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.