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F0761
E

Medication Carts Left Unlocked and Unattended

Atlanta, Georgia Survey Completed on 06-17-2025

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

Multiple instances were observed where medication carts were left unlocked and unattended by nursing staff, contrary to the facility's policy requiring all drugs and biologicals to be stored in locked compartments and only accessible to authorized personnel. During medication administration, an LPN left the cart unlocked while entering a resident's room, admitting to forgetting to secure it. On another occasion, a medication cart was found unlocked and unattended on the third floor, with gastrostomy supplements left exposed on top of the cart. Staff interviews revealed a lack of awareness regarding the ownership of the cart and failure to follow proper storage procedures. Additional observations on the fourth floor and near the nurse station documented medication carts left unlocked and unattended for several minutes, with no nurses present and residents in proximity to the unsecured carts. Further interviews with staff indicated that some nurses left medication carts unlocked due to distractions or leaving the facility in a hurry, with one LPN admitting to forgetting to lock the cart multiple times. The Interim Director of Nursing confirmed that the facility's policy mandates medication carts be locked when unattended and that only authorized personnel should have access. The repeated failure to secure medication carts as required by policy was confirmed through direct observation and staff interviews, demonstrating noncompliance with established medication storage protocols.

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