Failure to Properly Label and Date Insulin Pens
Penalty
Summary
The facility failed to ensure that insulin pens were labeled in accordance with currently accepted professional principles. During an observation of the first floor back medication cart, it was found that several insulin pens were opened and undated. Specifically, an aspart insulin pen for a resident, a glargine insulin pen for another resident, a lispro insulin pen that was not labeled with a resident's name, a degludec insulin pen for a different resident, and another aspart insulin pen for yet another resident were all found to be opened and undated. These findings were confirmed by Employee E11, a licensed nurse, during the observation. Further observation of the first floor middle medication cart revealed a glargine insulin pen for a resident that was also opened and undated. This was confirmed by Employee E5, another licensed nurse. The facility's policy on administering medications, dated April 2019, states that when opening a multi-dose container, the date opened should be recorded on the container, and insulin pens should be clearly labeled with the resident's name or other identifying information. The failure to adhere to this policy led to the deficiency noted in the report.
Plan Of Correction
1. R122, R25, R5, R380 open and undated medication were disposed of and replaced. 2. An initial audit was conducted of insulin pens to ensure they are properly labeled and dated. Variances were addressed at the time of the audit and placed on the facility audit tool. 3. DON/Designee will re-educate licensed nurses on proper labeling and dating insulin pens. 4. DON/Designee will conduct random audits on insulin pens being labeled and dated correctly. This audit will be conducted 3 times per week for 4 weeks then 1 time a month for 2 months. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.