Failure to Discard Undated Open Humalog Insulin Pen
Penalty
Summary
Surveyors identified a deficiency related to the labeling and storage of drugs and biologicals on a medication cart. Facility policy requires that all multi-dose medications be labeled with the date of first use to determine expiration or last use, and that any opened vial without a date should be discarded. Additionally, the policy and manufacturer guidelines specify that an opened Humalog insulin pen must be used within 28 days or discarded, even if insulin remains in the pen. During an observation, an open Humalog insulin pen was found on the medication cart without a resident name or a date indicating when it was opened. An LPN confirmed that the pen lacked both the resident name and the open date, making it impossible to determine the appropriate discard date. The LPN also acknowledged that the insulin pen should have been discarded according to policy.
Plan Of Correction
1. Humalog insulin pen with no resident name or date was discarded at the time of the survey and replaced with labeled & date of expiration tag. 2. At the time of the survey, all residents and medication carts were checked for any unlabeled/dated medications. 3. Verbal education was provided to the nursing staff regarding the requirement for labeling and dating medications when opened. The unit licensed staff will be provided education by the Director of Nursing and/or designee regarding labeling and dating multiple dose medications. 4. The Director of Nursing or designee will audit all medication carts to ensure all items are labeled with the date opened as indicated. Audits will be completed weekly for one month, then bi-weekly for 1 month, then monthly until substantial compliance is achieved. Results will be shared at the facility Quality Assurance and Performance Improvement committee. I Certify This Document to be a True and Correct Statement of Deficiencies and Approved Facility Plan of Correction for the Above-Identified Facility Survey