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F0761
E

Improper Medication Refrigerator Temperature Control

Pacific Grove, California Survey Completed on 04-25-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the medication refrigerator in the medication room was not maintained within the required temperature range of 36°F to 46°F. On inspection, the refrigerator was found to have a thick buildup of ice and temperatures as low as 28°F and 32°F, with medications stored inside. The Director of Nursing (DON) confirmed these findings and acknowledged that the ice buildup and low temperatures were not acceptable. Medications stored in the refrigerator included unopened vials of insulin, compounded Daptomycin, unopened bottles of latanoprost eyedrops, vials of tuberculin, an emergency kit containing insulin and Lorazepam, and doses of influenza vaccine, all of which had manufacturer or pharmacy labels indicating specific storage temperature requirements that were not met. A review of the medication refrigerator temperature log for the month showed seven instances where the temperature was recorded at 34°F, below the acceptable range. The DON stated that these temperatures were not acceptable and should have been reported by nursing staff. Facility policy requires that all drugs and biologicals be stored under proper temperature controls in locked compartments, but this was not followed as evidenced by the repeated low temperatures and lack of reporting or corrective action by staff.

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