Observations
Based on a review of policy and procedures and an interview with the facility director, the facility failed to document inspections of the medication storage area.
The findings include:
The regulation requires an inspection of the medication storage area. On December 6, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an inspection of the medication storage area will be completed and documented monthly by the nurse manager and completed and documented twice a year by the pharmacist. Inspections were reviewed for the months of November 2009 to November 2010. The facility failed to document the inspections of the medication storage area for the months of November 2009, December 2009, January 2010, February 2010, March 2010, April 2010, May 2010, June 2010, July 2010, August 2010, September 2010 and October 2010. November 2010 was documented.
The facility director confirmed that medication storage area inspections were not documented for the months identified above.
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Plan of Correction
The Nurse Manager will conduct monthly medication inspections including the medication storage area monthly and report this in the monthly PI/QI meetings. The Nurse Manager will ensure the pharmacist follows the appointed schedule for medication inspections two times/year. This will be monitored and followed up on by the Clinical Supervisor and Division Director. |