Unattended and Unsecured Medications on 200 Hall Medication Carts
Penalty
Summary
The deficiency involves failures to properly secure and store medications on two medication carts on the 200 hall. During an observation, a medication aide (MA A) was seen administering medications and left a medication card containing gabapentin 300 mg capsules on top of the 200-hall medication aide cart in a hallway where residents were present. MA A then entered a resident's room to administer medications, leaving the gabapentin card out of her view and unattended. MA A acknowledged that medications should not be left on top of the cart unattended, stated she should have returned the gabapentin to the inside of the cart before going into the room, and recognized that unattended medications could be picked up by residents or staff. In a separate observation, an LVN (LVN B) left an unlocked and unattended nurse medication cart on the 200 hall with a vial of insulin lispro 100 units/mL on top of the cart in front of a resident's room, while staff and residents were present in the area. LVN B exited the resident's room and confirmed it was her cart, stating she had forgotten to put the insulin back inside the cart and lock it before entering the room. She acknowledged that people could pick up medications left on top of the cart and could take medications from inside the cart when it was left unlocked and unattended. The DON stated that medications should not be left on top of medication carts, that carts should be locked whenever staff walk away or turn their backs, and that unattended medications and unlocked carts could result in residents or employees taking medications or residents ingesting them with adverse effects. The Administrator stated he expected medication carts to be locked when not under staff supervision and medications not to be left on top of carts, and that the DON was responsible for monitoring staff compliance. Facility policy on Storage of Medications required all drugs and biologicals to be stored in locked compartments and specified that unlocked medication carts are not to be left unattended.
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