Unsecured Medication Cart Left Unlocked and Out of Sight
Penalty
Summary
Facility staff failed to secure prescribed medications from possible unauthorized access when a medication cart was left unlocked and unattended in the nurses’ station area facing the lobby. During observation, an RN assigned to the cart was positioned on the opposite side of the lobby, facing a resident and with her back partially turned toward the cart, and a vase of flowers blocked her line of sight to the cart. The unlocked cart contained gabapentin, escitalopram, and multiple blood pressure medications. While the cart was unsecured, a confused resident was observed wandering toward the nurses’ station, and another RN, who was not assigned to the cart, redirected the resident and verbally acknowledged she would not leave the cart unsecured. The assigned RN later stated that medication carts are not typically left unlocked when staff walk away and admitted the cart should not have been left unlocked, explaining she had gone to give medications to a resident who was yelling that her taxi was waiting for an appointment. The DON stated that staff are expected to lock the cart if they are going to leave it unattended. A facility document titled “Protocol for Medication Administration” indicated that medication carts must be in the possession of the nurse or medication aide at all times and, when unlocked, must remain within eyesight of the nurse or medication aide at all times. These observations and statements showed that the cart was not kept within the nurse’s line of sight and was left unlocked contrary to facility protocol, resulting in unsecured medications accessible in a public area while a confused resident was nearby.
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