Unlocked and Unattended Medication Carts on Multiple Hallways
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication carts containing drugs and biologicals were locked when unattended, as required by facility policy and professional standards. Surveyors observed three of six medication carts on the 500 and 600 hallways left unlocked and unattended for several minutes. On one occasion, an unlocked and unattended cart was observed on the 600 hallway for three minutes until a licensed nurse walked by, locked it, and left. On another occasion on the 600 hallway, a certified medication aide returned to an already unlocked cart, used the computer, then walked away into a resident’s room, leaving the cart unlocked and unattended for two minutes before returning to prepare medications. A further observation on the 500 hallway showed an unlocked and unattended medication cart for three minutes while a licensed nurse was in a resident’s room; during this time, a cart drawer was opened without the nurse noticing. Staff interviews confirmed that the medication carts stored residents’ insulins and treatment supplies and that staff understood the expectation that carts must be locked when not in use or out of direct eyesight. The administrative nurse also stated that all medication carts were expected to be locked when unattended. The facility’s Medication Administration policy dated January 2021 documented that staff were to keep the cart in visible range or lock all items prior to going into a resident’s room.
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