Unlocked and Unattended Wound Care Cart Containing Medications
Penalty
Summary
Surveyors observed that the Station 2 wound care cart was left unlocked and unattended for at least seven minutes during a continuous observation period on a Sunday morning from 10:29 AM to 10:36 AM. During this time, there were no staff, residents, or visitors positioned so that they could see the cart. Multiple individuals, including housekeeping staff, nurse aides, visitors, and a resident, walked past the unlocked cart while it remained unattended. The cart was located at the nursing station, and no staff member was identified as the last person to access it. When the cart was inspected with a nurse at 10:39 AM, it was found to contain various wound care supplies and medications, including calcium alginate dressing, iodoform packing strips, collagen wound filler, xeroform medicated petrolatum dressing, zinc oxide paste, Silvasorb gel, diclofenac sodium topical gel 1%, 70% isopropyl alcohol, lidocaine ointment USP 5%, carbamide peroxide 6.5%, ciclopirox olamine cream USP 0.77%, nystatin cream USP 100,000, gentamicin sulfate cream USP 0.1%, and nystatin topical powder. The nurse interviewed stated that all nurses were responsible for the cart, acknowledged that it should be locked when unattended because it contained medications, and noted that many confused residents lived in the facility. The DON also stated that wound care carts should be locked at all times when not attended by a nurse due to safety concerns for confused residents.
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