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LAHEY HOSPITAL & MEDICAL CENTER, BURLINGTON
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observations, records reviewed and interview the Hospital failed to consistently follow their policy for medication and vaccine storage for two of two medication refrigerators.
Findings included:
The Surveyor interviewed the Tertiary Leader of the Surgical Intensive Care Unit (SICU) at 8:30 A.M. on 4/18/17. The Tertiary Leader of the Surgical Intensive Care Unit said that staff was required to complete the temperature log for the medication refrigerator daily.
The SICU Manual Temperature Monitoring Log for April 2017 indicated that five of the eighteen days lacked a temperature entry into the A.M. column and no P.M. entries had been charted. The continuous refrigerator temperature monitor was in place; however, the Surveyor observed the audible alarm feature had been turned off, thus, if the temperature fell out of range the alarm would not be heard.
The Surveyor interviewed the Pharmacist at 8:45 A.M. on 4/18/17. The Pharmacist said the medication refrigerator in the Surgical Intensive Care Unit contained vaccine storage so temperature monitoring of the refrigerator was required twice daily instead of the daily requirement for medication refrigerator monitoring.
The Surveyor interviewed the Nurse Manager of the Operating Room (OR) at 7:30 A.M. on 4/19/17.
The OR Manual Temperature Monitoring Log for April 2017 indicated that six of the eighteen days lacked a temperature entry into the A.M. column. The continuous refrigerator temperature monitor was in place; however, the Surveyor observed the audible alarm feature had been turned off, thus, if the temperature fell out of range the alarm would not be heard.