Failure to Maintain Proper Medication Refrigerator Temperatures and Documentation
Penalty
Summary
The facility failed to maintain proper refrigerator temperatures for medication storage in one of its medication storage rooms. Observations and temperature logs revealed that the medication refrigerator on Unit 1C was repeatedly documented as being out of the required temperature range on multiple dates, with recorded temperatures between 28°F and 32°F, which is below the facility's stated acceptable range of 36°F to 46°F. The refrigerator contained various medications, including insulin products, suppositories, ophthalmic solution, and intravenous medications. Staff interviews indicated that the responsibility for monitoring and documenting refrigerator temperatures fell to the overnight nurse, but there was a lack of awareness among staff and supervisors regarding the out-of-range readings. The Maintenance Director was not notified of the temperature issues, and the Director of Nursing Services was also unaware of the ongoing problem. Review of facility policy and interviews further revealed inconsistencies in the understanding of acceptable temperature ranges and the required actions when temperatures were out of range. The policy required notification of maintenance and the supervisor on duty if temperatures were not within the specified range, but this was not consistently followed. Additionally, temperature logs for the previous year were not provided upon request, indicating a lack of proper documentation and oversight in medication storage practices.