Unattended, Unlocked Medication Cart Left Accessible on Resident Hall
Penalty
Summary
Surveyors identified a deficiency in medication storage and security when the F-hall medication cart (MC A) was observed unattended and unlocked. On the morning of 09/30/2025, MC A was found partially in front of room F50 with the locking mechanism protruding outward, allowing surveyors to open drawers and view medications inside. At that time, LVN A was inside room F50 with a resident, with the privacy curtain pulled closed, and the medication cart was not within her direct observation. The facility’s Medication Storage Policy, dated 12/16/2024, requires all biologicals to be stored in locked compartments and specifies that during medication pass, medications must be under the direct observation of the person administering them or locked in the storage area/cart. During interviews, LVN A stated she had been trained on medication storage and acknowledged that the policy required narcotics and the medication cart to be locked, and that the cart should be locked every time it was out of the nurse’s sight. She admitted she forgot to lock the medication cart and the computer screen. The DON and ADM both confirmed that staff, including themselves, were trained on medication storage and that the policy required the medication cart to be locked whenever staff were not actively handing out medications or when the cart was not in the nurse’s eyesight. They each stated that the nurse or medication aide working from the cart was responsible for ensuring it was locked and that they monitored compliance through observation rounds, daily rounds, and audits. Both the DON and ADM stated they did not know why LVN A left the cart unlocked and unattended.
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