Controlled Substances Not Double-Locked and Improper Medication Refrigerator Temperatures
Penalty
Summary
Surveyors identified that controlled substances, including Ativan, Phenobarbital, Ultram, and Xanax, were not stored in accordance with facility policy and federal regulations. In three medication storage rooms, these Schedule IV drugs were kept in stock medication boxes on top of medication carts, sealed only with colored zip ties rather than being secured under a double-lock system as required. Nurses explained that the zip ties indicated whether drawers had been opened, and that two signatures were required when removing medications. However, no daily counts of these controlled substances were performed, and the inventory was managed by the pharmacy during restocking. The Director of Nursing confirmed that controlled substances should be locked and included in daily counts, but this was not being done for the stock medications. Additionally, surveyors observed that medication refrigerators in all three medication rooms were not maintained at appropriate temperatures for medication storage. Nurses reported that the night shift was responsible for logging refrigerator temperatures, but logs and direct readings showed temperatures as low as 32°F, which is below the manufacturer's recommended range for medications such as insulin and Trulicity. The posted temperature guidelines in the medication rooms did not align with manufacturer instructions, and the facility's insulin storage policy did not specify the required temperature range. Nurses stated that if temperatures were out of range, they would notify the DON or maintenance, but logs showed repeated instances of temperatures below the acceptable range without clear evidence of corrective action. The surveyors found that the facility's practices for storing controlled substances and maintaining proper medication storage temperatures did not comply with professional standards, facility policy, or manufacturer guidelines. These deficiencies were confirmed through staff interviews, direct observation, and review of facility documentation, with both the Director of Nursing and Assistant Director of Nursing acknowledging the issues.