Unlocked and Unattended Medication Carts on Two Halls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments on two medication carts observed during survey. On the south hall, surveyors observed a nurse cart at 8:28 AM positioned in front of the nurse’s station with the drawers facing the hallway, unlocked and unattended, with no staff present at the nurse’s station. RN A, who reported she was not regular staff and only worked when needed, stated in interview that she had been passing medications to a resident and forgot to lock the cart when she walked away. RN A acknowledged that carts needed to be locked when staff walked away to prevent residents from taking medications that did not belong to them and stated it was the nurse’s responsibility to ensure carts were locked when they leave them. On the north hall, surveyors observed another nurse cart at 8:42 AM in front of a resident’s room with drawers facing the doorway, also unlocked and unattended, while the nurse was at the north hall nurse’s station around the corner from the cart. LPN B, who regularly worked the 6:00 AM to 2:30 PM shift on the north hall, stated she could see her cart, no residents were around when she walked away, and she had only gone to the nurse’s station for a few seconds. When asked how leaving the cart unlocked could have affected residents, she responded that it could not affect them since it was within her sight and then pushed the cart away from the surveyor and did not answer further questions. The DON stated that staff assigned to nurse or medication carts were responsible for ensuring they were locked before leaving them unattended, that both nurses were experienced and should not have left their carts unlocked, and that leaving a cart unlocked placed residents at risk of taking medications not prescribed for them, which could cause adverse effects including illness or hospitalization. Facility policy on Medication Storage required that during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.
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