Unsecured Medication Carts and Medications Left Unattended
Penalty
Summary
The deficiency involves the facility’s failure to keep medication carts locked and medications secured in accordance with facility policy and professional standards. The facility’s “Administering Medication” policy, last revised April 2020, requires that medication carts remain closed and locked when out of sight of the medication nurse or aide, and that no medications are kept on top of the cart. On Nursing Unit A, surveyors observed an unlocked medication cart in the hallway outside a resident room with no nursing staff present nearby. During an interview, the assigned licensed nurse (Employee E8) acknowledged that the cart should have been locked. On subsequent observations on Nursing Unit A, surveyors again found unsecured medications and unlocked carts. One observation revealed an unlocked cart outside a resident’s room with crushed medication in a plastic cup left on top of the cart while the assigned nurse (Employee E9) was at the opposite end of the hallway speaking with other staff. Another observation showed an unlocked cart in the hallway between two residents’ rooms with an unidentified blister pack partially covered by papers on top of the cart, while the same nurse (Employee E9) was at the end of the hallway speaking with staff. In interviews, Employee E9 confirmed that the cart should have been locked and medications should not be left unattended on top, and the DON confirmed that staff are required to lock medication carts when unattended and are not permitted to leave medications unsecured on top of the carts.
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