Failure to Label Insulin Pens Upon Removal from Refrigeration
Penalty
Summary
Facility staff failed to ensure that insulin pens for two residents were properly labeled when removed from refrigerated storage and placed in the medication cart. For one resident with severe cognitive impairment and diabetes mellitus, the insulin Glargine pen was observed on the medication cart without a date label. The LPN confirmed that the pen was not dated at the time it was moved from refrigeration. Similarly, another resident with diabetes mellitus and other chronic conditions had a Lantus SoloStar insulin pen in the medication cart that was also not dated, as confirmed by the LPN. Interviews with the Director of Nursing and Assistant Director of Nursing verified that insulin is required to be dated when removed from refrigeration and placed in the medication cart. Review of the manufacturer's guidelines and facility policy indicated that medications, including insulin, should be labeled with the date when taken from refrigeration. The observations and staff confirmations demonstrated that the facility did not follow these labeling requirements for insulin storage for the two affected residents.