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F0761
D

Medication Cart Left Unlocked and Unattended

Commerce, Texas Survey Completed on 05-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a medication cart in the South Hall was left unlocked and unattended next to the nurse's station. During an observation, the cart was found unlocked while the assigned nurse, LVN C, was on break and not present in the hallway. A housekeeper moved the unlocked cart, believing the nurse was on break. LVN C later confirmed that she had been on break and had forgotten to lock the cart, acknowledging the importance of keeping it secured, especially given the presence of dementia patients in the facility. Interviews with the DON and the Administrator confirmed that facility policy requires medication carts to be locked at all times when not in use or out of the nurse's view. Record review of the facility's policy, revised April 2007, also indicated that medication carts must be securely locked when unattended. The failure to secure the medication cart was directly observed and acknowledged by staff, constituting a breach of professional standards for the storage of drugs and biologicals.

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