Failure to Date and Dispose of Insulin Pens per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure that insulin pens for multiple residents were properly dated upon opening and disposed of according to manufacturer guidelines. During observations of the East and North medication carts, opened insulin pens for several residents were found without dates indicating when they were first used. In one instance, an insulin pen was dated but had not been discarded after the recommended period. Interviews with nursing staff confirmed that insulin should be dated when opened, but there was uncertainty regarding the correct duration for use and disposal timelines. The facility's policies required dating multi-dose containers upon opening, but did not specify the required duration for insulin use after opening. Medical records showed that the affected residents had diagnoses including diabetes, hypertension, congestive heart failure, and other conditions requiring insulin therapy. Manufacturer guidelines for the insulins in use specified strict timeframes for discarding opened pens, ranging from 28 days to eight weeks, which were not consistently followed. The facility's failure to date and dispose of insulin as required had the potential to affect all residents with insulin orders, as staff could not determine when the insulin should be discarded.
Plan Of Correction
Resident #8, 11, 63, and 131 were immediately assessed and found to have no adverse effects. All residents with insulin orders have the ability to be affected. Resident #8, 11, 63, and 131 insulin pens were immediately dated by nursing. All insulin pens were audited immediately to ensure proper storage and labeling. Education was provided to all nursing staff by the DON on 5/22/25 regarding proper medication storage. The DON/Designee will audit 3 insulin pens per week for 4 weeks to ensure they are appropriately dated. Results will be reviewed in QAPI.