Insulin Pens Administered Without Required Pharmacy Labels
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a licensed practical nurse (LPN) administered insulin to a resident using a Novolog insulin pen that did not have a pharmacy prescription label affixed to it. The insulin pen was stored in a plastic tube labeled with the resident's name in handwriting, but the pen itself lacked any identifying information, such as the resident's name, medication name, dosage, or instructions for use. Additional insulin pens for the same resident were found in a pharmacy-labeled bag, but none of the individual pens had prescription labels. Both nurses stated they identified the pen as belonging to the resident based on its storage location, not by any label on the pen itself. The RN acknowledged that the pen had been used consistently without a pharmacy label and that the pharmacy typically provided labeled pens. Review of the resident's electronic medical record confirmed that the resident was prescribed scheduled and as-needed doses of Novolog insulin. The facility's policy required that all medications be labeled in accordance with state and federal laws, with labels permanently affixed to the medication container and containing specific identifying and instructional information. The administrator confirmed that the pharmacy supplied the insulin pens and that the pens should have had complete prescription labels. The policy also stated that improperly labeled medications should be rejected and returned to the pharmacy.