Improper Storage of Controlled Substances in Medication Room
Penalty
Summary
Surveyors observed that in the Second Floor medication room, four two-milligram vials of lorazepam, a Schedule IV controlled substance, were stored in a locked box inside the medication room refrigerator. However, the locked box was not permanently affixed to the refrigerator and could be easily removed. Additionally, the refrigerator itself was not locked. During an interview, the Director of Nursing confirmed that the controlled medication storage box should have been permanently affixed to the refrigerator, indicating that the facility failed to ensure proper security measures for controlled substances as required.
Plan Of Correction
The second floor controlled medication box was permanently affixed to the refrigerator. An initial audit was conducted by DON or designee on all other controlled medication storage boxes in the facility. Nursing staff will be in-educated by DON/designee on proper storage and ensuring all controlled medications are secured and locked, in a permanently affixed compartment at all times. The DON/Designee will complete audits weekly x 8, monthly x 2 to ensure controlled medication storage boxes are secured and locked, in a permanently affixed compartment. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.