Improper Medication Labeling and Storage, Including Unsafe Refrigeration of Insulin
Penalty
Summary
During an inspection of a medication cart, multiple prescription medications were found without proper labeling or resident identification. Items included a Humalog (insulin lispro) KwikPen, a pill organizer containing various oral tablets, and an Albuterol Sulfate Inhaler, none of which had prescription labels or clear identifiers. These medications were not separated from other facility-stocked medications and were stored in a manner that did not prevent potential medication administration errors. A registered nurse acknowledged that these medications were brought in by a resident and admitted they had not been properly labeled or verified for use. Additionally, a medication refrigerator in the facility's medication storage area was observed to be operating at 14°F, well below the required refrigeration range. Multiple insulin vials and pens were stored inside, all labeled to be refrigerated but not frozen. The nursing supervisor confirmed that staff had not previously identified or addressed the unsafe storage condition, and there was no indication that the affected insulin had been evaluated for safety or removed from use.