Failure to Label and Discard Multi-Dose Insulin Pens per Manufacturer Guidelines
Penalty
Summary
Nursing staff failed to properly label and store multi-dose insulin pens in accordance with professional standards and manufacturer instructions. During an observation of a medication cart on the Pine Hall unit, one multi-dose insulin pen of Insulin Lispro and three multi-dose insulin pens of Insulin Glargine were found to be opened and in use without being labeled with the date they were initially opened. Additionally, one Insulin Glargine pen was labeled with an opening date of April 16, 2025, but was still available for use beyond the manufacturer-recommended discard date of 28 days after opening. Interviews with a registered nurse and the Nursing Home Administrator confirmed that the insulin pens were being used without proper labeling and that one pen was used past its recommended discard date. Facility policy requires multi-use medication vials and bottles to be labeled accordingly and for nursing staff to maintain proper medication storage, including labeling. These findings were in violation of both facility policy and state regulations regarding pharmacy and nursing services.