Improper Storage of Refrigerated Controlled Medications
Penalty
Summary
Surveyors found that the facility failed to store resident medications, specifically Lorazepam vials, according to pharmacy labeling and manufacturer recommendations. Multiple vials labeled as requiring refrigeration were instead kept unrefrigerated in the narcotic box within the nurse's medication cart. This was observed for four residents with diagnoses including seizure disorders, epilepsy, and anxiety disorder, all of whom had physician orders for Lorazepam to be administered intramuscularly as needed. The medication refrigerator in the medication room was found to lack a lock, and staff reported that this was the reason for storing the vials in the cart rather than in the refrigerator. Interviews with nursing staff revealed a lack of clarity regarding proper storage procedures, with one agency nurse unaware of the requirement to refrigerate the Lorazepam vials. The Director of Nursing confirmed that medications labeled for refrigeration must be stored accordingly and acknowledged that improper storage could affect medication potency. The facility's policy requires refrigerated medications to be kept at specific temperatures in a locked box within the refrigerator, but this was not followed for the Lorazepam vials in question.