Unlabeled Insulin Vials and Pens Found in Medication Carts
Penalty
Summary
Surveyors found that the facility failed to remove and discard unlabeled multi-dose insulin vials and insulin delivery pens from four active medication carts. This deficiency affected 17 residents who were reviewed for insulin usage. During observations, multiple instances were noted where unlabeled insulin vials and pens were stored in the insulin compartments of medication carts across several halls, including Harmony I, Harmony II, and the respiratory unit. Interviews with nursing staff confirmed that these insulin vials and pens were not labeled with resident names and should not be used or stored in the carts. The facility's policies require that all medications be stored in containers with pharmacy labels and be prepared and administered only to the residents for whom they were ordered. The Director of Nursing and nursing staff acknowledged that insulin vials and pens not labeled with a resident's name should be immediately discarded and never used for any resident. Despite these policies, the presence of unlabeled insulin in active medication carts was observed for all residents in the facility who regularly utilize insulin.