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F0761
D

Medication Cart Left Unlocked and Unattended

Pilot Point, Texas Survey Completed on 06-05-2025

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 nurse's medication cart was observed parked in front of the nurses' station with its centralized metal lock protruding and not engaged, leaving the drawers unlocked and accessible. The cart, facing the hallway, contained various over-the-counter medications, blister packs, and insulins, and was left unattended while several staff and residents passed by. The cart could be easily opened, and it was only locked after the nurse returned to the area. Interviews with the ADON, Administrator, DON, and the nurse involved confirmed that the cart should not have been left unlocked and unattended, as this allowed unauthorized individuals, including residents, staff, and visitors, to potentially access the medications. The facility's policy requires medication carts to be locked when out of sight of the medication nurse or aide, which was not followed in this instance. The nurse admitted to leaving the cart unlocked due to being in a hurry, acknowledging that it was not an acceptable reason.

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