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F0761
D

Improper Use and Labeling of Insulin Pen for Resident

Victoria, Texas Survey Completed on 04-09-2025

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

A deficiency occurred when a licensed vocational nurse (LVN) administered insulin to a resident using an insulin pen that was labeled for a different resident. The LVN handwrote the receiving resident's last name on the cap of the insulin pen, which still bore the pharmacy label for the original resident. This action was taken because the resident's own supply of Insulin Lispro was depleted, and the next delivery was not scheduled until later that evening. The LVN checked the medication room refrigerator and confirmed there was no extra supply available for the resident, leading her to use the insulin pen labeled for another resident. The resident who received the insulin had a diagnosis of Type 2 diabetes mellitus and was assessed as having intact cognition. The facility's policy explicitly prohibits administering medications prescribed for one resident to another and forbids borrowing medications between residents. The Regional Compliance Nurse confirmed that the LVN's actions were not in accordance with facility policy or professional standards, as the correct procedure would have been to use medication from the emergency kit if the resident's supply was unavailable.

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