Improper Storage and Labeling of Biologicals and Medical Supplies
Penalty
Summary
The facility failed to properly store biologicals and medical supplies according to established protocols and manufacturer recommendations. Specifically, COVID-19 and influenza vaccines were stored in a medication refrigerator on the 2nd floor, where temperature logs showed that the internal temperature fell below the acceptable range of 36-46 degrees Fahrenheit on three separate occasions. Despite facility policy requiring staff to notify the Facilities Manager and file a work order when temperatures are out of range, no work orders were filed for these incidents. Staff interviews confirmed that both the Charge RN and Facilities Manager were not notified as required, and that vaccines were indeed stored in the affected refrigerator during these periods. Additionally, the facility failed to ensure that medical supplies, specifically 3M 1860 N95 masks stored in the West 3 medication cart, were labeled with expiration dates. During an observation, unbagged N95 masks were found in the medication cart without their original packaging, and staff were unable to reference the expiration date as the box could not be located. The Director of Nursing confirmed the expectation that all supplies should have an expiration date available for staff reference, which was not met in this instance. These failures were identified through observation, interview, and record review, and were in direct violation of the facility's own policies and manufacturer guidelines. The lack of proper storage and labeling placed residents at risk for receiving compromised or ineffective biologicals and medical supplies.