Improper Storage and Loss of Refrigerated Controlled Medications
Penalty
Summary
A deficiency occurred when medications requiring refrigeration, specifically four vials of Ativan injectable, were not properly secured during the defrosting and subsequent removal of a medication room refrigerator. The facility's policy required that all medications be appropriately stored and remain with a licensed individual at all times when removed from designated storage. However, during the defrosting process, one LPN removed only a single vial of Ativan for immediate use, leaving the remaining four vials in a locked box inside the refrigerator. There was a miscommunication between the two LPNs involved, with each believing the other had removed all the medications. The refrigerator, which contained the locked box with the four vials of Ativan, was then taken outside by one of the LPNs after it was found to be malfunctioning. Maintenance staff, unaware that medications remained inside, later transported the refrigerator to a landfill as scrap. The locked box containing the Ativan was not retrieved before disposal, and the medications were not accounted for until the following day, when staff realized the refrigerator was missing and the vials could not be recovered. Interviews with the Interim DON, Interim Administrator, and the LPNs involved confirmed that the Ativan vials were not properly removed and secured prior to the refrigerator being taken out of the facility. Documentation and time card records corroborated the sequence of events, showing that the medications were left unattended and ultimately lost due to failed communication and lack of adherence to medication storage protocols.