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F0761
D

Medication Cart Left Unlocked and Unattended

Kerrville, Texas Survey Completed on 06-27-2025

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 medication cart assigned to the 200 hall was observed left unlocked and unattended near the entrance closest to the resident activities room. The cart was not secured at the time of observation, and staff interviews confirmed that the cart was under the responsibility of an LVN who had walked away, mistakenly believing it was locked. Another staff member subsequently locked the cart after noticing it was unsecured. The Director of Nursing (DON) confirmed that the facility's expectation is for medication carts to be locked when not in use to prevent unauthorized access. Review of the facility's policy on medication labeling and storage, revised in February 2023, specifies that all compartments containing medications and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or accessible. The failure to secure the medication cart was directly observed and acknowledged by staff, with the DON reiterating the importance of keeping medication carts locked to prevent unauthorized access.

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