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F0761
E

Failure to Properly Label and Discard Multi-Dose Insulin Pens

Carbondale, Pennsylvania Survey Completed on 07-31-2025

Penalty

Fine: $206,733
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to comply with its own policy and accepted professional standards regarding the labeling and storage of multi-dose medications. During an inspection of a medication cart on the Lilac Hall unit, one multi-dose insulin pen of Insulin Degludec and one multi-dose pen of Insulin Glargine were found to be opened and in use without being labeled with the date they were first accessed. Additionally, a multi-dose insulin pen of Insulin Aspart was found with a date indicating it had been opened on July 1, 2025, but was still available for use past its manufacturer-recommended discard date of July 28, 2025. Interviews with an LPN and the DON confirmed that these insulin pens were opened, available for resident use, and not properly dated or discarded according to facility policy and manufacturer guidelines. The facility's policy requires that all multi-use medication vials or bottles be labeled with the date they are opened to ensure proper tracking for expiration, which was not followed in these instances.

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