Failure to Date, Label, and Discard Opened Insulin Pens as Required
Penalty
Summary
Nurses and Certified Medication Aides (CMAs) failed to properly date and discard opened insulin pens within the required 28-day period for three residents. Observations revealed that one insulin pen was opened and not dated, another was opened and dated but not discarded after 28 days, and a third was opened, undated, and unlabeled, making it impossible to identify the owner. The facility's policy and the manufacturer's instructions both require that opened multidose insulin pens be dated and discarded within 28 days, and that each pen be labeled with the resident's name upon first use. Interviews with staff, including a nurse, the Director of Nursing (DON), and the Consultant Pharmacist (CP), confirmed that the expectation is to date, label, and timely discard insulin pens. However, the observed practices did not align with these requirements, resulting in the potential for residents to receive insulin that was either expired or not properly identified. The records confirmed that the affected residents had active orders for Insulin Lispro.