F0761

D

Unattended, Unlocked Medication Cart Accessible in Lobby

Harker Heights, Texas Survey Completed on 02-28-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to improper storage and security of medications when one of three medication carts reviewed was found unattended, unlocked, and accessible in the main lobby area. During an observation, the medication cart assigned to the 300 hall was located in an unsecured public area with the locking mechanism protruding outward, allowing the surveyor to open drawers and take photographs without being noticed by the RN or LVN on duty. The cart contained drugs and biologicals that were not secured in accordance with facility policy and professional standards, and it was accessible to staff, residents, and passers-by.

In interviews, the RN stated the cart belonged to the LVN assigned to the 300 hall and acknowledged that residents could access the cart and take medications not intended for them. The RN also stated she was the charge nurse and supervisor on duty and responsible for ensuring medication carts remained locked. The DON stated that medication carts were supposed to be locked at all times with no exceptions and that all nurses should have known this practice, referencing an existing facility policy on medication cart security. The LVN, who had worked at the facility for 15 or 16 years and was responsible for the 300 hall cart, acknowledged that policy required carts to remain locked at all times because someone could access them, and confirmed that residents were at risk of taking medications not prescribed to them. The administrator similarly stated that medication carts were to be locked at all times when not in use and that the assigned nurse, as well as any staff or management who observed an unlocked cart, were responsible for ensuring its security. Review of the written policy confirmed that medication carts and their contents were to be kept closed, secured, and/or in line of sight when not in use.