Improper Refrigeration of Medications Outside Required Temperature Range
Penalty
Summary
Surveyors identified a failure to maintain a medication refrigerator within the facility’s required temperature range for medications stored for four residents. During an observation of the 3rd floor medication refrigerator, the unit felt warm and the internal thermometer read 54°F. After the refrigerator door was closed and approximately 25 minutes passed, a recheck showed the internal temperature had increased to 60°F. The facility’s temperature log, provided by the DON, specified that the medication refrigerator temperature must be maintained between 36°F and 46°F, and staff interviewed acknowledged that medications such as unopened insulin pens, eye drops, and Trulicity should be stored within that 36–46°F range. At the time of the observation, the refrigerator contained an unopened Humalog Lispro insulin pen for one resident, an unopened Humalog insulin pen for another resident, Latanoprost 0.005% ophthalmic solution eye drops for a third resident, and a Dulaglutide (Trulicity) 1.5 mg/0.5 mL auto-injector for a fourth resident. The LPN present and the 3rd floor supervisor both confirmed that the refrigerator temperature was outside the acceptable range needed to maintain the effectiveness of these medications. Maintenance staff later stated that the refrigerator was not cooling due to excessive ice buildup, which resulted in the unit not functioning properly, but at the time of the surveyor’s observation, these medications remained stored in a refrigerator that was operating above the facility’s specified temperature parameters.
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