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UPMC MERCY
VENTILATION, LIGHT, TEMPERATURE CONTROLS
Tag No.: A0726
Based on review of facility documentation and staff interview (EMP), it was determined that the facility failed to ensure proper temperature controls for the storage of drugs.
Findings include:
Review of facility policy and procedure "Medication Refrigerators" dated August 2017, revealed, "Temperature Control 1. The Pharmacy Department will utilize either digital (Hi/Lo) thermometer probes or standard thermometers to record/monitor daily temperatures of medication refrigerators on nursing units, specialty units, and within the pharmacy area. The digital (Hi/Lo) thermometers must be used on areas that are not opened 7 days per week."
Review of facility documentation "refrigerator temperatures" for the month of February revealed temperatures were not completed daily for the medication refrigerators on Unit 6A, Labor and Delivery Unit, Neonatal Intensive Care Unit, Cardiac Cath Lab and the Intensive Care Unit.
Interview with EMP2 on April 24, 2018, at approximately 1:45 PM confirmed the above findings and revealed "I know."