F0761

F

Failure to Routinely Monitor and Document Vaccine Refrigerator Temperatures

Clayton, New Mexico Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to the storage and monitoring of medications in the facility’s locked medication storage room, specifically the vaccine refrigerator. During an observation on 02/10/26 at 12:55 pm, the vaccine fridge temperature log for January 2025 through February 2026 was found to be incomplete. Numerous dates on the day shift log were left blank, including extended periods such as 01/01/25 through 01/18/25, 01/20/25 through 06/01/25, 06/03/25 through 07/23/25, 07/25/25 through 09/12/25, 09/15/25 through 09/31/25, and multiple additional gaps through 02/08/26. The night shift log also contained multiple missing entries on specific dates throughout 2025, indicating that temperatures were not consistently documented as required.

In an interview on 02/10/26 at 12:56 pm, an LPN confirmed that the vaccine medication fridge temperature log was not being completed routinely and stated that nurses are responsible for completing all temperature logs. On 02/11/26 at 1:38 pm, the DON further confirmed there had been inconsistency with checking the vaccine fridge temperature log. The DON stated that the fridge temperature should be checked once per shift and documented on the appropriate log, and acknowledged that this did not occur as required.