Unsecured Refrigerated Controlled Medication in Medication Storage Room
Penalty
Summary
Surveyors identified a deficiency in the storage and security of a controlled medication requiring refrigeration in one of the medication storage rooms. During an observation of the 103 medication storage room refrigerator with a nurse, a 30 ml bottle of liquid lorazepam 2 mg/ml, a controlled benzodiazepine, was found stored in the refrigerator door rather than in the permanently affixed internal lock box. The nurse reported that staff did not have a key to the internal lock box and that there was no lock on the refrigerator door, and she acknowledged that the lorazepam should have been secured inside the affixed lock box. The DON later stated she had been unaware that nurses did not have a key to the internal lock box and confirmed that controlled medications, including lorazepam, were supposed to be stored in the secured internal lock box. The Administrator also reported being unaware that staff could not access the internal lock box and stated an expectation that refrigerated controlled medications be stored in the secured box inside the refrigerator. This situation resulted in a controlled drug being stored in an unsecured location within the medication room refrigerator, contrary to the facility’s stated practice that controlled medications requiring refrigeration be kept in a separately locked, permanently affixed compartment.
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