Expired Insulin Pen Used for Resident
Penalty
Summary
A resident's insulin (Humalog Kwikpen) was found to have been used for eight days after its expiration date, as observed during a medication cart review with an LPN. The insulin pen was labeled with both the date it was opened and its expiration date, but it was not discarded when expired. The LPN confirmed that this expired insulin pen was the only one available for the resident and that it had been used to administer sliding scale insulin doses. The resident's blood glucose was checked three times daily, and insulin was administered as needed based on those results. Medication administration records showed that the resident received insulin from the expired pen on multiple occasions after the expiration date. The Director of Nursing stated that insulin pens are to be used for 28 days after opening, with the opening and expiration dates documented on the pen, and that expired pens should be discarded and replaced. Facility policy requires that outdated or deteriorated drugs be immediately withdrawn from stock and disposed of according to procedures. Despite these policies, the expired insulin pen remained in use, and a replacement was not ordered or made available in a timely manner.