Deficiency in Medication Labeling and Expiration Management
Penalty
Summary
The facility failed to properly label and manage multi-dose containers of insulin and Tuberculin solution, leading to deficiencies in medication storage and expiration management. Observations revealed that insulin pens and vials on the Gold and Red Units' medication carts were not labeled with the date they were opened, making it impossible to determine their discard dates. Additionally, an opened multi-dose vial of insulin was found to be expired by five days. Staff interviews confirmed that these items should have been labeled with the opened date to ensure proper discard timing. Further observations in the Red Unit medication room identified an opened multi-dose vial of Tuberculin solution that was expired by seven days. Staff confirmed that this vial should have been discarded according to the facility's policy, which requires opened vials to be labeled with the date opened and a new expiration date. The failure to adhere to these policies resulted in the presence of expired medications in the facility, which was confirmed by staff interviews.
Plan Of Correction
Medication carts were immediately audited to ensure that any multidose vials of insulin, insulin pens, or Tuberculin solutions were dated with open date and that they had not expired since open per manufacturer guidelines. The Director of nursing or designee will educate licensed staff on medication storage policy and insulin policy to ensure that staff understands they have to date multidose insulin vials, insulin pens, and Tuberculin solutions when opened and they have to follow manufacturer guidelines of when it expires and not to be used after that date. The Director of Nursing or designee will audit all medication carts to ensure that insulin vials, insulin pens, and TB solution is dated with an open date and not used beyond expire date. Audits will be completed on 1 cart a day 3x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is met.