Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and security of medications in two key areas: the medication refrigerator and a medication cart (MC #1). During observation, the medication refrigerator was found to be operating at 52°F, which is above the recommended storage temperature range of 36°F to 46°F for several medications stored inside, including Lantus, NovoLog, Trulicity, and Repatha. Staff interviews revealed that while there was a policy requiring daily temperature checks by the night shift, there was confusion among staff regarding who was responsible for monitoring and ensuring the refrigerator maintained the correct temperature. The Director of Nursing (DON) confirmed the required temperature range and acknowledged that the facility had not established clear monitoring responsibilities following a recent change in refrigerator equipment. Additionally, MC #1 was observed unattended and unlocked in a hallway, containing both prescription and over-the-counter medications. No staff were present in the vicinity at the time of observation. Interviews with medication aides and nursing staff confirmed that facility policy requires medication carts to be locked whenever unattended and that both nurses and medication aides are responsible for ensuring this. Staff acknowledged that leaving the cart unlocked could allow unauthorized access to medications. Review of the facility's medication storage policy confirmed that all drugs and biologicals must be stored in locked compartments and under proper temperature controls. Despite this, both the medication refrigerator and MC #1 were not secured according to policy at the time of the survey, and staff were unable to provide a clear explanation for these lapses. The findings were based on direct observation, staff interviews, and review of facility policies and medication storage guidelines.