Improper Storage of Controlled Substance in Medication Room Refrigerator
Penalty
Summary
A vial of Lorazepam Oral Concentrate USP 2 mg/ml, a Schedule IV controlled substance, was found stored in the door of the medication room refrigerator, outside of the designated double lock box. The lock box intended for controlled substances was not permanently affixed to the refrigerator and had a key left in the lock. An LPN, who was agency staff, confirmed that the lock box had been unaffixed and the key left in place since they began working at the facility. The LPN also confirmed that the Ativan should have been stored and locked in the lock box, and that the key should not have been left in the box. The medication count for Ativan was verified as correct in the narcotic box. The DON confirmed that the Ativan was inappropriately stored and not double locked as required, and that the key should have been kept with the charge nurse rather than left in the box. Both the consultant pharmacist and the DON stated that the expectation was for Lorazepam Oral Concentrate to be stored double locked in a permanently affixed compartment within the refrigerator. The facility's medication policy indicated that Schedule II drugs and backup stock of Schedule III, IV, and V medications are to be stored under double lock and key, with Schedule II medications specifically requiring storage in a separately locked, permanently affixed compartment when stored with other medications.