Failure to Date Opened Insulin Pens in Medication Storage
Penalty
Summary
Facility staff failed to ensure that all insulin pens for multiple residents were labeled with the date they were opened, as required by both manufacturer instructions and facility policy. During observations, insulin pens for four residents were found in the nursing cart without open dates. The labels on these insulin pens specified that they should be discarded 28 days after opening, but the absence of open dates made it impossible to determine if the insulin was still safe and effective for use. For each of the four residents, record reviews confirmed active orders for daily insulin administration, and medication administration records showed that the insulin was being given as prescribed. Interviews with the LVN revealed that the nurse was unaware of when the insulin pens had been opened and therefore could not determine if the insulin should be discarded. The LVN acknowledged that the pens should have been dated upon opening, in accordance with the label instructions, but did not know if or when this had occurred. The DON confirmed that facility policy requires all insulin to be dated when opened and discarded after 28 days. The DON stated that nurses are responsible for labeling insulin with the open date and that periodic reviews of nursing carts are conducted by DON and ADON. However, the DON was unable to explain why the nurses had not written the open dates on the insulin pens, acknowledging that this omission could result in improper use of insulin.