Expired and Improperly Labeled Insulin Found in Medication Cart
Penalty
Summary
The facility failed to ensure proper medication management as evidenced by the presence of expired and improperly labeled insulin in one of the medication carts. During a review of the facility's policy on medication storage, it was noted that medications and biologicals should be stored safely and securely, following the manufacturer's recommendations. Specifically, insulin vials are to be stored in the refrigerator until opened, then dated and placed in the medication cart. However, during an observation of the [NAME] medication cart, a Humalog insulin vial was found with an opened date that exceeded the 28-day discard period recommended by the manufacturer. Additionally, a Lantus insulin vial was found without an open date, making it impossible to determine its discard date. During an interview, Registered Nurse Employee E2 confirmed the oversight, acknowledging that the Humalog insulin was expired and should have been discarded, and that the Lantus insulin lacked an open date, preventing staff from determining its expiration. This deficiency was identified during a survey, which included a review of facility policy, manufacturer's recommendations, observations, and staff interviews. The failure to adhere to proper medication labeling and storage protocols resulted in a violation of the facility's policy and state regulations regarding pharmacy and nursing services.
Plan Of Correction
1) 12/09/2024: Expired and undated insulin discarded from medication cart at the time of discovery. 2) All other medication carts were audited for expired/undated insulin the day the expired insulin was discovered. 3) FT/PT LPN's and RN's to be educated on proper med storage. 4) Medication carts will be audited on each unit for expired meds 1x weekly for 3 weeks then 1x monthly x2 by Director of Nursing. 5) Results of the audits to be reviewed at quarterly QAPI meeting.