F0761

E

Unlocked Medication Cart Left Unattended on Unit

Golden Valley, Minnesota Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to keep medications stored securely in a medication cart on the 400 unit. During an observation, an employee identified as E-I walked away from a medication cart in the hallway between resident rooms, leaving it unlocked and unattended from 12:27 p.m. to 12:37 p.m. During this time, one resident wheeled by the cart and two nursing assistants walked past it. The Director of Social Services checked only the narcotics drawer, confirmed it was locked, and then left, while the rest of the cart remained unlocked. E-I later acknowledged that the cart was unlocked when she left and stated it should have been locked to prevent other staff and residents from taking medications from the cart, which could make them sick.

In a separate observation the same day at 2:27 p.m., the same medication cart on the 400 unit was again found unlocked and unattended in the hallway between resident rooms. From 2:27 p.m. to 2:47 p.m., nursing assistants walked by the unlocked cart five times. At 2:47 p.m., the DON walked by, pushed the lock to secure the cart, and stated it was not good that the cart was unlocked, that medications could go missing, and that the cart was supposed to be locked when staff walked away. The facility’s Storage of Medications policy dated May 2022 stated that the medication supply was accessible only to licensed nursing personnel or staff lawfully authorized to administer medications, and that medication carts were to be locked when not attended by authorized personnel.