F0761

D

Unlocked Overflow Medication Cart Left Unattended Near Resident

Weatherford, Texas Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to medication storage and security when an overflow medication cart (Cart #1) on the south side of the facility was observed unlocked and unattended across from the nurses' station. During the observation, a male resident in a wheelchair was approximately four feet from the unattended cart, which contained blister packs of blood pressure medications, anti-diabetic medications, diuretics, potassium supplements, anti-platelet medications, and blood thinners. The cart was not under the direct supervision of staff at the time it was observed.

In an interview, an LVN stated that Cart #1 was new and used to store overflow medications, and acknowledged she was responsible for ensuring the cart was locked when not in use. She reported that she had been called to the secure unit and forgot to lock the cart, and stated that if a resident opened the cart, they could have taken a medication not intended for them and had a negative reaction. In a separate interview, the DON stated that medication carts should be locked when not in use and acknowledged that if a cart was unlocked and unattended, a resident, visitor, or staff member could steal or ingest a medication not meant for them and possibly have an adverse reaction. The DON also stated that nurses were responsible for monitoring medication carts to ensure they were locked, and that she did not have a set routine to monitor the carts. Review of the facility’s Medication Labeling and Storage policy, dated 2001, showed that all medications and biologicals were to be stored in locked compartments, with carts and trays not left unattended if open or otherwise available to others, and that only authorized personnel were to have access to keys.