Improper Medication Storage and Inadequate Temperature Monitoring
Penalty
Summary
Surveyors observed that medications and vaccines were not stored properly in multiple medication storage refrigerators across three wings of the facility. On two separate wings, dormitory-style combination refrigerator/freezer units with significant ice buildup were used to store medications, which is inappropriate due to temperature fluctuations. In one of these refrigerators, an expired vial of Prevnar 20 pneumonia vaccine was found available for use, 43 days past its expiration date. Additionally, there was a lack of evidence that refrigerator temperatures were being monitored in the immunization refrigerator on the South Wing. Temperature logbooks for the medication and immunization refrigerators were reviewed and found to have missing documentation for several days in June 2025. Specifically, the South Wing medication refrigerator log was missing temperatures for 2 of 25 days, the South Wing immunization refrigerator log was missing temperatures for 21 of 25 days, and the West Wing medication refrigerator log was missing temperatures for 6 of 25 days. These findings were confirmed through interviews with the Unit/Nurse Manager/Infection Control Preventionist and the Director of Nursing.