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F0761
D

Failure to Secure Controlled Medications in Locked, Permanently Affixed Storage

Colorado Springs, Colorado Survey Completed on 05-15-2025

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

The facility failed to ensure that controlled medications and biologicals were stored in accordance with accepted professional standards. Specifically, during an observation of the medication storage room, a locked narcotic medication box containing two vials of liquid lorazepam was found inside a medication storage refrigerator that was unlocked. Furthermore, the narcotic medication lock box itself was not permanently affixed to the inside of the refrigerator, contrary to facility policy and professional standards that require controlled substances to be stored in a separately locked, permanently affixed compartment. Interviews with nursing staff confirmed that the medication storage refrigerator and the narcotic medication lock box should both be locked at all times to prevent unauthorized access. The registered nurse present acknowledged forgetting to lock the refrigerator, and the DON was unaware that the narcotic lock box needed to be permanently affixed inside the refrigerator. The LPN also stated that controlled medications should always be secured in the lock box with the refrigerator locked, emphasizing the importance of restricted access to these medications.

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