Unlocked and Unattended Medication Cart Left Accessible in Hallway
Penalty
Summary
The deficiency involves failure to ensure medications were stored securely in locked compartments accessible only to designated staff. The facility had a census of 29 residents, with one medication room, three medication carts, and one treatment cart. During an observation, a licensed nurse approached a medication cart parked directly outside the nurse's station, prepared medications in a small cup, locked only the computer screen, and then walked away from the cart, which remained unlocked. The cart’s lock was positioned outward, indicating it was not engaged and that the contents were accessible to anyone who attempted to open it. The nurse then entered a resident’s room down the hall, leaving the unlocked cart unattended and out of staff visual range. Upon returning, she logged back into the computer, prepared medications for another resident, again locked the monitor screen, closed the medication drawer, and walked down the hall into another resident’s room, once more leaving the cart unlocked and unsupervised. During interview, the nurse acknowledged that the medication cart and computer monitor should be locked every time they are left unattended. The administrative nurse also stated she expected staff to lock the medication cart before walking away. The facility’s Medication Labeling and Storage policy required all medications to be stored in a secure, locked location accessible only to designated staff.
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