Unattended Unlocked Medication Carts During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked when unattended, as required for the secure storage of drugs and biologicals. Surveyors observed multiple instances on the same day where Registered Nurse (RN) #201 and RN #200 prepared medications at unlocked medication carts positioned in the hallway outside residents’ rooms and then entered the rooms without securing the carts. These observations occurred during medication administration for several residents, including Resident #85 and Resident #77 for RN #201, and Residents #21, #88, #84, and #52 for RN #200. During interviews conducted shortly after each observation, both RN #201 and RN #200 confirmed that they had not locked the medication carts before leaving them unattended. The report notes that this failure had the potential to affect nine cognitively impaired and independently mobile residents on the 200 and 300 halls, identified during the survey as Residents #17, #34, #40, #50, #57, #59, #63, #87, and #93. The cited deficiency is specifically related to the requirement that all drugs and biologicals be stored in locked compartments, with separately locked compartments for controlled drugs.
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