Expired Insulin Pens and Missing Opened Date on Medication Cart
Penalty
Summary
Facility staff failed to properly manage insulin pens on one of four medication carts reviewed for medication storage. Specifically, four insulin pens (three Insulin Lispro/Humalog and one Insulin Glargine/Lantus) were found on the 700-hall medication cart with expiration dates that had passed according to the manufacturer's guidelines, which require pens to be discarded 28 days after opening. Additionally, one Insulin Glargine (Lantus) pen was found in use without an opened date recorded, despite 60 of 300 units having been administered. Interviews with staff revealed that medication aides were not responsible for administering insulin and therefore did not check for expired insulin, while nurses were expected to check for expired medications and record opened dates on insulin pens. The Unit Manager and DON both confirmed that nurses were responsible for checking medication carts for expired medications at least weekly, and that insulin pens should be checked daily and prior to use. The expired insulin pens and the pen lacking an opened date were not identified or discarded as required.