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F0761
D

Medication Cart Left Unlocked and Unattended

San Antonio, Texas Survey Completed on 05-30-2025

Penalty

Fine: $25,500
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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 medication cart on Unit 1 was observed left unlocked and unattended in front of the nurse's station, facing a main pathway where six residents were present in wheelchairs. The cart was assigned to a medication aide, who stated she believed she had locked the cart, but the lock must have popped open. The aide acknowledged that the cart should not be left unlocked and unattended, as only facility staff should have access to it, and she was the only one with the key. The LVN present confirmed the cart was assigned to the medication aide, and the administrator also identified the cart as belonging to her. Interviews with the ADON and the RN Corporate Nurse confirmed that facility policy requires medication carts to be locked when unattended to prevent unauthorized access. Both staff members stated that leaving the cart unlocked could allow residents or others to access medications. A review of the facility's policy document titled 'Security of Medication Cart' indicated that medication carts must be securely locked at all times when out of the nurse's view and when not in use, they must be locked and parked at the nurse's station or inside the medication room.

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