Failure to Discard Opened Insulin Pens Within 28 Days
Penalty
Summary
The facility failed to ensure that nurses and Certified Medication Aides (CMAs) properly labeled and discarded opened insulin pens within 28 days of opening, as required by manufacturer instructions and facility policy. Observations of the medication cart revealed multiple insulin pens for five residents that were opened and dated, but not discarded after 28 days. The facility's Medication Storage Policy required staff to note the date on the label when insulin vials and pens were first used, but did not specifically address discarding insulin pens within 28 days. Manufacturer instructions for Insulin Glargine, Insulin Lispro, and Insulin Aspart all directed that opened vials or pens should be discarded after 28 days, regardless of remaining insulin. Interviews with nursing staff, the unit manager, the Director of Nursing (DON), and the consultant pharmacist confirmed that the expectation was for staff to date insulin pens upon opening and discard them after 28 days. Despite this, the opened insulin pens for five residents were not discarded as required. Physician orders confirmed that these residents were actively receiving insulin therapy. The failure to follow proper labeling and disposal procedures for insulin pens was observed and acknowledged by staff and management during the survey.