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F0761
E

Failure to Properly Label, Store, and Discard Insulin and Medications

Evergreen Park, Illinois Survey Completed on 05-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with its medication labeling and storage policies by not discarding medications belonging to discharged residents and by not ensuring that open and expiration dates were labeled on insulin pens and vials. During observations, multiple instances were found where insulin bottles and pens for several residents were opened but not dated, and in one case, insulin for a discharged resident remained on the medication cart instead of being discarded. Staff interviews confirmed that facility policy requires opened insulin to be dated and medications for discharged residents to be removed from the cart, but these procedures were not followed. Specifically, insulin bottles and pens for residents with Type 2 Diabetes Mellitus were found on medication carts without open or expiration dates, and in one case, insulin for a resident who had been discharged was still present and not discarded. Staff, including nurses and the assistant director of nursing, acknowledged that insulin should be dated upon opening and discarded after expiration, but these requirements were not met for several residents reviewed. The facility's own policy states that all opened medication vials should be labeled with the date opened and discarded within a specified timeframe, but this was not consistently implemented.

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