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F0761
E

Failure to Properly Label and Remove Expired Insulin

Duluth, Minnesota Survey Completed on 04-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors found that the facility failed to ensure biologic medications, specifically insulin aspart, were properly labeled with a pharmacy label indicating the resident's name and prescription information. During an observation of a medication cart in the Harbor Light community, an LPN confirmed the presence of an insulin aspart mix pen in the top drawer without knowledge of its owner. The LPN also acknowledged that the cart was checked regularly for expired or beyond-use medications, but the insulin pen was not labeled with the required information and had not been removed after its beyond-use date (BUD). Further interviews revealed that the DON expected insulin to be labeled with the resident's name, the date it was opened, and to be removed from use after reaching its BUD. The facility's policy on labeling medication containers required all medications to be properly labeled with specific information, including the resident's name, prescriber's name, pharmacy details, drug information, prescription number, dispensing date, cautionary statements, expiration date, and directions for use. The policy also required checking the expiration or BUD prior to medication administration. These requirements were not met for the insulin aspart pen found in the medication cart.

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