Expired Insulin Pens Found and Administered from Medication Cart
Penalty
Summary
Surveyors observed that two expired insulin pens, Basaglar 100unit/ML KWIKPEN and Novolin R 100unit/ML Flexpen, were present in the medication cart during a medication administration review. The Basaglar pen had been opened and was past its 28-day discard date for one resident, while the Novolin R pen was also expired and associated with another resident. Both expired insulin pens were found in the top drawer of the medication cart, and photographic evidence was obtained to document the finding. During an interview, the nurse responsible for the cart confirmed the expiration dates and acknowledged that she had not checked her cart for expired medications in some time. A review of the Medication Administration Record (MAR) showed that the expired Novolin R insulin had been administered multiple times to a resident according to a sliding scale order, and the expired Basaglar insulin had also been administered to another resident. Facility policy requires that discontinued or outdated medications be placed in a designated, secure location for destruction, but this procedure was not followed in these instances.