F0761

D

Unlocked Medication Cart Left Unattended With Medications Accessible

Austin, Texas Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that medications on a medication cart were securely stored and inaccessible to unauthorized individuals. During an observation of the nurse’s station, Medication Cart #1 (MC #1) was found unlocked and unattended while an RN sat inside the nurse’s station, out of view of the cart. Another RN walked past the unlocked cart and entered the nurse’s station without locking it. Residents were observed walking by the unlocked cart, which contained prescribed creams, prescribed drugs, over-the-counter medications, narcotics, and injectable antibiotics. The facility’s written policy required that all medications and biologicals be securely stored in a locked cabinet or cart inaccessible to residents and visitors, and that only authorized staff have access to keys or codes for medication storage areas.

In interviews, the RN assigned to the cart stated she had been trained on medication storage and acknowledged that the policy required the medication cart to be locked any time staff stepped away from it, and that the nurse using the cart was responsible for locking it. She also stated that all staff were expected to monitor and lock any cart found unlocked, and acknowledged that a resident might get into the medications if the cart was left unattended and unlocked. The DON confirmed she had been trained on medication storage and reiterated that medication carts must be locked when not in use or when the nurse is not present, and that medication aides and nurses passing medications are responsible for locking the carts. The administrator, though not clinical, also stated his expectation that carts be locked when not in use and confirmed that any staff member could lock an unattended cart. Both the DON and the administrator stated they did not know why the RN left MC #1 unlocked.