F0761

D

Unlocked Treatment Cart Left Unattended and Out of Nurse’s View

Windsor, North Carolina Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to keep medications stored in a locked treatment cart when not under direct supervision. During an observation on 1/5/26 at 8:32 AM, Treatment Cart #1 on the 100-hall was found with its locking mechanism in the unlocked position while positioned outside an open resident room. The cart was oriented toward the resident’s room, and the resident’s privacy curtain was drawn around the resident and the Wound Care Nurse, who was providing care inside the room. A transport driver was approximately 15 feet away from the unlocked cart, and no other individuals were observed nearby. The surveyor was able to stand between the resident’s doorway and the unlocked cart without touching it, confirming that the cart was unattended and accessible while unlocked.

At 8:35 AM, the Wound Care Nurse returned from behind the privacy curtain and acknowledged that she had been unable to visualize the treatment cart while in the resident’s room and was unaware of the surveyor’s presence near the cart. Upon inspection, she confirmed that the cart was unlocked and stated it should be locked when unattended, also confirming it had been out of her sight while she was providing care. At 8:36 AM, the contents of Treatment Cart #1 were observed to include multiple topical medications and treatment products, such as A&D ointment, Manuka Honey, Chymosin topical, Cadexomer Iodine Gel, diclofenac sodium 1% gel, triamcinolone 0.5% cream, Collagenase Santyl ointment, triamcinolone acetonide 0.1% cream, nystatin topical powder, and Dyna-hex 4% chlorhexidine gluconate solution. At 8:41 AM, the DON stated that any treatment or medication cart that is out of view of the nurse should be locked, confirming that the observed situation did not meet facility expectations for medication security.