Failure to Consistently Monitor and Document Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that medication refrigerator temperatures were routinely monitored and documented as required by its Medication Storage in Refrigerator/Freezer policy. That policy stated that medications and biologicals must be stored at appropriate temperatures per manufacturers' specifications, that medication storage areas should be monitored at least once daily, and that vaccine storage temperatures should be monitored twice daily. During inspection of the A-Wing medication storage room with an RN, surveyors observed two refrigerators: a black refrigerator storing narcotic medications and a silver refrigerator storing vaccines and insulins. Review of the temperature logs showed multiple days with no recorded temperatures. For the silver refrigerator, morning shift temperatures were missing on 5 of 28 days in February and 8 of 20 days in March, and PM shift temperatures were missing on 2 of 28 days in February and 5 of 20 days in March. For the black refrigerator, morning shift temperatures were missing on 5 of 28 days in February and 10 of 20 days in March, and PM shift temperatures were missing on 3 of 28 days in February and 5 of 20 days in March. When the RCM reviewed the A-Wing refrigerator temperature logs, she stated she did not think temperature monitoring was being done as required. In the D-Wing medication storage room, inspected with the SDC, the refrigerator containing narcotic medications also had inconsistently documented temperatures. Review of those logs showed that on the AM shift, temperatures were not recorded on 15 of 30 days in January and 16 of 28 days in February, and on the PM shift, temperatures were not recorded on 2 of 28 days in February and 2 of 20 days in March. The SDC stated there should not be blanks on the medication room refrigerator temperature logs. The deficient practice created the potential for harm if residents received vaccines or medications with reduced potency and safety from improper storage.
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