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F0761
D

Failure to Secure Medication Carts

Fort Worth, Texas Survey Completed on 12-05-2025

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

The facility failed to ensure that all drugs and biologicals were securely stored in accordance with professional standards and facility policy. On two separate occasions, medication carts were observed left unlocked and unattended in the hallway near the nurse's station. On one occasion, a medication aide (MA A) left her medication cart unlocked and unattended while she was across the hall at the nurse's station. When questioned, MA A initially believed the cart was locked but was able to open the drawer, confirming it was not secured. She later stated that she was distracted and thought she had locked the cart before leaving it. MA A acknowledged that the unlocked cart contained over-the-counter medications and recognized the risk of residents accessing or stealing medications. On another occasion, a different medication aide (MA D) left her medication cart unlocked and unattended near the nurse's station. When approached by the surveyor, MA D admitted that she knew the cart was not locked and acknowledged that it should have been secured. The facility's policy requires that all drugs and biologicals be stored in locked compartments and that medication carts be locked or attended by authorized personnel at all times. The Director of Nursing (DON) confirmed that the expectation is for staff to double-check that medication carts are locked when unattended and recognized the risk of residents accessing medications from an unlocked cart.

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