Failure to Date Insulin Pens Upon Removal from Refrigeration
Penalty
Summary
Surveyors observed that insulin pen-injectors for three residents were not properly labeled with the date they were removed from refrigerated storage and placed in the medication cart for administration. Specifically, Lantus, Glargine, and Tresiba insulin pens were found in the Aspen medication cart without the required dating. This was confirmed during an observation with an LPN, who verified that none of the pens had been dated when removed from stock. The Director of Nursing and the consulting pharmacist both confirmed that facility policy and professional standards require insulin vials and pen-injectors to be dated when removed from refrigeration for use. A review of the facility's medication storage policy indicated that certain medications, including multiple dose injectable vials, require an expiration date shorter than the manufacturer’s date once opened, to ensure medication purity and potency. The failure to date the insulin pens upon removal from refrigeration affected three of the 26 residents with medications stored in the Aspen medication cart, out of a total facility census of 148.
Plan Of Correction
Plan of Correction for F0761 - Label/Store Drugs and Biologicals During the observation of the Aspen Med Cart, it was found that resident's #23, #29, and #128 insulin pen injectors were not dated when removed from the refrigerator and placed in the cart. Correction was made by the staff member at the time of observation. A full house audit of all medication carts was conducted by DNS/designee on 6/4/2025. Any expired, improperly labeled, or unsecured medications were discarded or corrected. Staff were educated by DNS/designee on 6/4/2025 on the facility medication storage policy to reinforce labeling standards, including expiration dates, and the proper way to store insulin and date. The DNS/designee will conduct weekly audits on medication carts for 4 weeks, then 2 times a month for 2 months. All findings will be reviewed by the QAA committee, which meets monthly and as needed. Compliance date of July 10, 2025.