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F0761
E

Unattended and Unlocked Medication and Treatment Carts

Kerrville, Texas Survey Completed on 04-06-2025

Penalty

Fine: $14,020
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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

Facility staff failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to them. During an observation, both a medication cart and a treatment cart were found unattended, unsupervised, and unlocked in a hallway. Over a period of five minutes, several staff members, including a housekeeper, a driver, and a CNA, walked past the unsecured carts. The medication aide assigned to the cart stated she always locked the cart when leaving it but was unsure how it became unlocked. The LVN responsible for the treatment cart admitted to unintentionally leaving it unlocked while providing care in a resident's room. The Director of Nursing (DON) and the Administrator were both made aware of the situation. The facility's policy requires all medications to be stored in locked compartments with access limited to authorized personnel. The failure to secure the medication and treatment carts was directly observed and acknowledged by the staff involved, with the risk for harm identified as unsecured medications.

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