Failure to Monitor Vaccine Refrigerator Temperatures and Remove Expired Medications
Penalty
Summary
Surveyors identified that the facility failed to properly monitor and document the temperature of a medication refrigerator containing vaccines in one of the medication rooms. Specifically, the temperature log for the refrigerator in Medication Room Station 2 showed that temperatures were only recorded once daily over a specified period, despite facility policy and manufacturer guidelines requiring twice-daily monitoring. The Assistant Director of Nursing (ADON) confirmed that several licensed nurses did not monitor or document the refrigerator temperature as required, making it unclear whether the vaccines were stored within the recommended temperature range. Additionally, the facility failed to remove and discard expired budesonide inhalation solutions from a medication cart. An open foil pouch containing four remaining budesonide inhalation solutions for a resident with COPD was found stored at room temperature beyond the two-week period recommended by the manufacturer after opening. Both the LVN and the DON acknowledged that the expired medication should have been removed and that several licensed nurses failed to do so, contrary to facility policy and manufacturer instructions. The facility's policies require that medications and biologicals be stored according to manufacturer recommendations, with expired or deteriorated medications immediately removed from stock. The surveyors' review of the facility's policies and the manufacturer's guidelines confirmed that these requirements were not met in the instances observed, resulting in the presence of expired medications and inadequate monitoring of vaccine storage conditions.