F0761

D

Unlocked and Unattended Wound Care Medication Cart

Brownsville, Texas Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

Surveyors observed that a wound treatment cart on the 300 hallway was left unlocked and unattended by an RN at 6:03 p.m. The cart contained medications needed for residents’ wound care and wound care supplies. When the surveyor notified the RN that the cart was unlocked, the RN locked it and acknowledged she was responsible for the treatment cart and was expected to lock it whenever she walked away. She stated that if the cart was left unlocked, a resident could open a drawer and take a medication that was not prescribed for them.

In a subsequent interview, the DON stated that numerous staff, including herself and the ADON, were responsible for ensuring medication carts were locked and that her expectation was that staff lock the cart when walking away from it. The DON stated that if the cart was left unlocked, a resident or visitor could grab medication from the cart and it could harm them. Review of the facility’s “Medication Storage” policy showed that medications and biologicals must be stored properly and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended only by persons with authorized access. The observed unlocked and unattended wound care cart was not in accordance with this policy or with accepted professional principles for medication storage and security.