Improper Medication Storage Temperature Control
Penalty
Summary
The facility failed to store medications under proper temperature controls in the medication room, as required by federal regulations. The facility's policy, last revised in August 2020, mandates that medications be stored within temperature ranges specified by the United States Pharmacopeia (USP) and the Centers for Disease Control (CDC). Specifically, refrigerated medications should be kept between 36°F and 46°F. However, an observation on April 22, 2025, revealed that the thermometer in the medication room refrigerator was placed inside the freezer section, which had significant ice build-up, and the temperature was recorded at 20°F, well below the required range. A review of the facility's medication room refrigerator temperature log for April 2025 showed inconsistent temperature recordings, with several days missing entries. Temperatures recorded on various days were either below the required range or not recorded at all, indicating a failure to maintain and monitor appropriate storage conditions. During an interview, the Nursing Home Administrator and Director of Nursing acknowledged the expectation for medications to be stored at appropriate temperatures and for daily temperature recordings to be maintained, which was not adhered to in this instance.
Plan Of Correction
1. A new thermometer was purchased for the medication room refrigerator. 2. Medication room refrigerator was cleaned and defrosted. 3. DON or designee will provide education to nursing staff in regard to routine checking of temperatures and that all medication should be stored between 36-46 degrees. 4. An audit will be conducted by NHA or designee weekly x 4 weeks, then monthly x 2 months to ensure that all medications are stored between 36-46 degrees. 5. Results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.