Illegible Insulin Pen Labeling Found on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were labeled in accordance with professional standards, specifically regarding the labeling of insulin pens. During an observation of a medication cart, a smeared and illegible date was found on an insulin pen assigned to a male resident with Type 2 diabetes mellitus and severe cognitive impairment. The resident's care plan indicated a risk for hyper/hypoglycemia, and physician orders required the use of NovoLOG insulin three times daily. Interviews with multiple LVNs and the DON confirmed that insulin pens are to be dated upon opening, with the date placed in a manner to prevent smearing, preferably on the paper label. However, the observed pen's date was not legible, and staff acknowledged that this could result from improper placement or smudging of the date. Review of the facility's medication storage policy confirmed that medications requiring an open date should be clearly dated when opened. Despite this policy, the insulin pen in question did not have a legible open date, and staff interviews revealed inconsistent practices regarding where and how the date was applied. The deficiency was identified through direct observation, record review, and staff interviews, all of which indicated a failure to maintain clear and legible labeling of insulin pens as required.