Failure to Monitor and Document Medication Refrigerator Temperatures
Penalty
Summary
Surveyors identified that the facility failed to consistently monitor and document temperature controls for medication and vaccine refrigerators in two medication storage rooms. During observations, it was noted that these refrigerators contained various vaccines and multi-use vials, including Pneumococcal 20, influenza vaccinations, and Tuberculin Purified Protein. Review of the facility's temperature logs for the months of March, April, and May revealed significant gaps in documentation, with many days lacking evidence of the required twice-daily temperature readings. Specifically, one refrigerator was missing readings for 15, 24, and 25 days in March, April, and May, respectively, while another refrigerator was missing readings for 31, 28, and 30 days in the same months. During interviews, facility staff confirmed the findings and stated that they follow CDC guidelines for vaccine and medication storage, which require temperature checks and documentation at least twice daily. The lack of consistent temperature monitoring and documentation was confirmed by both the surveyor's review and staff interviews, indicating noncompliance with accepted professional standards and CDC guidelines for medication and vaccine storage.