Failure to Maintain Proper Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that refrigerated medications and biologicals were stored at temperatures in accordance with both facility policy and manufacturer specifications. During an observation at a nursing station, a medication refrigerator was found to contain various medications, including vaccines, insulin, and other injectables, which require storage between 36°F and 46°F. Review of the refrigerator temperature logs from January to June 2025 revealed multiple instances where the temperature fell below the required range, with readings as low as 25°F on one occasion and frequent readings of 34°F and 35°F on numerous days and shifts. Nursing staff and the DON confirmed that the expected practice was to monitor and document refrigerator temperatures at the start of each shift and to take corrective action if temperatures were out of range. Interviews with nursing staff indicated that when the refrigerator temperature was found to be out of range, staff were expected to adjust the thermostat and recheck the temperature after a short interval. If the temperature did not return to the acceptable range, maintenance was to be notified. However, the logs showed repeated failures to maintain the correct temperature, and there were also instances of missing temperature documentation. The DON acknowledged these lapses and confirmed that the facility's policy required strict adherence to temperature monitoring and documentation protocols. Manufacturer instructions for all medications stored in the refrigerator, including Afluria, Latanoprost, Ozempic, Retacrit, Semglee, and Tubersol PPD, specified storage within the 36°F to 46°F range. The facility's own policy also required medications needing refrigeration to be kept within this range. The repeated failure to maintain proper storage temperatures and to consistently document temperature readings constituted a deficiency in the facility's medication management practices.