Failure to Consistently Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to consistently monitor and document the medication refrigerator temperatures in the medication storage room, as required to ensure safe storage of drugs and biologicals. Review of the temperature log posted on the refrigerator showed that temperature checks were not recorded on nine occasions in June, eleven occasions in July, and nine occasions in August. When temperatures were documented, they were within the safe range, but the lack of consistent monitoring meant there were multiple undocumented periods. The refrigerator contained ten boxes of unopened tuberculin solution, an injectable medication used for tuberculosis screening. Staff interviews revealed that it was the responsibility of the night shift nurse to check and record the refrigerator temperatures daily. However, the Infection Preventionist acknowledged that this monitoring was not performed consistently. The failure to document refrigerator temperatures as required was observed during a review of the medication storage room, and the issue was confirmed by staff.