Unsecured Prepared Medications Left Unattended on Medication Cart
Penalty
Summary
The deficiency involves unsecured medications left unattended on a medication cart after being prepared for administration to a resident. On 3/3/26 at 9:10 AM, an RN (V5) prepared 19 different morning medications for a resident (R1) and placed them in several cups on top of the medication cart. The RN then entered the resident’s room carrying only the resident’s insulin to check blood sugar levels and administer the insulin. The medication cart, with the remaining 19 prepared medications on top, was pushed against the wall past the resident’s doorway and was not within the RN’s line of vision. During this time, another nurse, an LPN/Infection Preventionist (V4), was observed coming up the hall and was asked whether it was acceptable to leave medications on top of the cart when the nurse goes into a room. V4 stated it was not acceptable to leave medications on top of the medication cart unattended and later confirmed that, since the medications had already been prepared, they should have been placed back into the locked medication cart so other residents could not access or grab them. The facility’s policy dated 05/2025 requires resident-specific medications to be stored in a locked cabinet or cart accessible only to authorized staff, with Schedule II controlled medications stored under a double-lock system.
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