Failure to Properly Label Insulin Pens for a Resident
Penalty
Summary
A deficiency was identified when a resident with type 2 diabetes was administered insulin using a NovoLog FlexPen that was not properly labeled with the resident's name or the date it was opened. During medication administration, an LPN retrieved the insulin pen from the emergency kit, attached a needle, primed, and administered the insulin without ensuring the pen was labeled according to facility policy. The pen only had a manufacturer label and an E-Kit sticker, with a blank space for the resident's name and no date of opening. The LPN confirmed that the labeling was incomplete and acknowledged the expectation for both the resident's name and the date opened to be documented on the pen label. Further inspection of the medication cabinet revealed a second insulin pen (Toujeo Solostar) that was labeled with the resident's name but also lacked the date it was opened. Interviews with nursing staff, including an RN case manager and the DON, confirmed that facility policy required insulin pens to be labeled with both the resident's name and the date opened. The facility's Safe Injection Practice policy specifically stated that insulin pens should be dedicated to one resident, not used if unassigned or unlabeled, and that labels should be affixed directly to the pen.