Controlled Medications Not Permanently Affixed in Locked Refrigerator Compartment
Penalty
Summary
Surveyors found that the facility failed to store controlled medications in accordance with both facility policy and regulatory requirements. Specifically, controlled substances requiring refrigeration, including Lorazepam and Morphine, were observed stored in a clear plastic locked container inside a medication room refrigerator. This container was not permanently affixed to the refrigerator, contrary to the facility's policy, which requires that such boxes be attached to the inside of the refrigerator to prevent removal. The Director of Nursing (DON) and a Registered Nurse (RN) both confirmed that the locked box was not permanently affixed and were unaware of the requirement for permanent attachment. The DON stated that the double-locked system in place consisted of the medication room door and the lock on the medication box, with keys managed through the Omnicell system. Interviews with the DON, RN, and the Administrator revealed a lack of awareness regarding the specific requirement for permanently affixed storage for refrigerated controlled substances. The facility's policy, dated 05/01/20, clearly outlines that controlled substances needing refrigeration must be stored within a locked box that is attached to the inside of the refrigerator. Despite this, the observed practice did not meet this standard, resulting in a deficiency related to the secure storage of controlled medications.