Failure to Date Opened Insulin Pens for Multiple Residents
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens for four residents were dated when first opened, as required by both facility policy and professional standards. During an observation of the medication carts, it was found that insulin pens for these residents did not have dates indicating when they had been accessed. The facility's policies specify that all multi-use vials must be dated upon first use and discarded within 28 days unless otherwise specified by the manufacturer. Record reviews confirmed that these residents had orders for various types of insulin, including Glargine, Novolog, and Insulin Aspart, administered on scheduled and sliding scale regimens for diabetes management. Interviews with an LPN and the Director of Nursing confirmed that insulin is required to be dated when opened to prevent use beyond the recommended period. The lack of dating on the insulin pens meant there was no way to ensure the insulin was not being used past the effective date, which is contrary to both facility policy and accepted professional practice. The facility census at the time was 45, and six residents were identified as receiving insulin injections.