Failure to Properly Label and Store Insulin Medications
Penalty
Summary
The facility failed to ensure that insulin medications were properly labeled and stored according to professional standards and facility policy. During observations of two medication carts, surveyors found multiple insulin pens in use without open or expiration dates documented, as well as insulin pens that were expired but still present on the cart. Additionally, unopened prefilled insulin syringes and pens were found unrefrigerated, contrary to storage requirements. The facility's own policy requires all medications to be labeled with expiration dates and appropriate instructions, and for insulin pens, the date opened must be written on the pen to ensure use within the recommended timeframe. Interviews with nursing staff revealed that while pharmacy staff are responsible for placing medications in the refrigerator during their bi-monthly visits, it is the responsibility of the unit manager and nurses to check the carts and ensure proper labeling and storage. However, lapses were identified, such as insulin pens without open dates, expired pens not removed in a timely manner, and unopened insulin not being refrigerated. The Director of Nursing confirmed that education on insulin management is provided by the Interventionist Nurse or unit manager, but at the time of the survey, the Interventionist Nurse was on leave.