Failure to Properly Date and Store Medications in Medication Cart
Penalty
Summary
Surveyors observed that an opened Humalog (insulin) pen was found undated in the top drawer of a medication cart during a medication pass with an LPN. The LPN confirmed the insulin pen was open and should have been dated but was unsure why it was not. Additionally, five loose, unidentifiable pills were found in the same medication cart drawer. The LPN, who identified as a new nurse, could not explain how the loose pills ended up in the drawer and stated that management was checking medication carts weekly. Interviews with the unit manager and the Director of Nursing confirmed that insulin should be dated upon opening and that staff are expected to follow facility procedures for medication storage and handling. Facility policy requires that all medications be stored in properly labeled containers, with opened medications such as insulin dated and assigned a new expiration date. The presence of undated insulin and loose pills in the medication cart indicated a failure to adhere to these established protocols.