Failure to Properly Label and Remove Expired Insulin Medications
Penalty
Summary
Surveyors found that the facility failed to ensure medications were properly labeled with open and expiration dates and failed to ensure expired medications were not administered on one of three medication carts reviewed. Facility policies required that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, and that expiration or beyond-use dates be checked prior to administration, with the date of opening recorded on multi-dose containers. However, observations revealed a Humalog Insulin Pen that had been opened on June 20, 2025, was still present on the cart without an expiration date, even though it should have expired 28 days after opening. Additional observations on the same medication cart included an unopened and undated Humalog Insulin Pen, two open and undated insulin aspart pens, and one open and undated insulin glargine vial. These findings indicate that the facility did not consistently follow its own policies or manufacturer instructions regarding the labeling and storage of insulin products, resulting in the presence of expired and undated medications on the medication cart.
Plan Of Correction
The 5 undated/expired insulin pens/vials were discarded. An audit was completed of the medication cart to ensure that insulin pens/vials are dated when opened and undated/expired are discarded immediately. Education will be completed by the DON/designee for licensed nurses on the policy for dating medications with shortened expiration dates when open. The DON/designee will audit 6 medication carts to ensure insulin pens/vials are dated weekly for 4 weeks then monthly for 2 months. The results of the audits will be reviewed by the Quality Assessment and Assurance Committee for the need to complete further audits.