Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 010006 (X3) Date Survey Completed 07/15/2010
Name of Provider or Supplier North Alabama Medical Center Street Address, City, State 1701 Veterans Drive, Florence, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0726 VENTILATION, LIGHT, TEMPERATURE CONTROLS
CFR(s): 482.41(c)(4)

There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.


This STANDARD is not met as evidenced by:
On 7/14/10 at 9:00 AM, the surveyor observed medication pass on 6 West. During this observation, Employee Identifier (EI) # 5, the Registered Nurse obtained Intravenous (IV) Venofer from a medication refrigerator. The surveyor observed an excessive amount of ice accumulation on the freezer portion of the refrigerator. On 7/14/10 at 9:30 AM, the surveyor showed the ice accumulation on the freezer portion of this refrigerator to EI # 7, the Nurse Manager, who verified it was excessive and would call maintenance to replace the refrigerator. 28327 Based on observation and policy review, the facility failed to assure all medications requiring refrigeration were stored properly in the Pharmacy, 3 West and 6 West. This had the potential to affect all patients. Findings Include: Policy: Medication Storage ... Medications requiring refrigeration will be stored in a refrigerator which will be used exclusively for this purpose and refrigerator temperatures will be set at 2-8 degrees Celsius (C) and monitored daily on medication refrigeration log... If temperature falls outside this range, the refrigerator temperature control will be adjusted and the temperature rechecked. If the temperature still is out of range, Plant Operations will be called. Refrigerator/Freezer Temperature Log Appropriate Refrigerator Range = 32 degrees Fahrenheit (F) to 41 degrees F. Appropriate Freezer = less than (<) 32 degrees F. A tour of the Pharmacy conducted on 7/13/10 at 2:00 P.M. by the surveyor, Employee Identifier (E.I.) # 3, Case Management Manager, and E.I. # 6, Assistant Director of Pharmacy, revealed the following: a. medications stored in the Break Room freezer with no temperature log found. b. medications stored in the main room freezer with no temperature log completed since May 25, 2010. A tour of 3 West conducted on 7/14/10 at 12:40 P.M. by the surveyor and E.I. # 1, the RN manager 3 West, revealed medications stored in the Pyxis refrigerator. The freezer compartment of the refrigerator was found to have an excessive ice buildup. A review of the temperature log revealed the following temperatures logged: a. 7/13/10 = 60 b. 7/14/10 = 59 There was no documentation that the temperature had been adjusted or that Plant Operations had been notified.