Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
A deficiency occurred when an insulin flex pen (Aspart) used for diabetes management was found on a medication cart without a resident's name labeled on it. The pen was assumed by an LVN to belong to a specific resident, who was a female with cerebral palsy, type 2 diabetes mellitus, mild intellectual disabilities, and severe cognitive impairment. The resident was dependent on staff for activities of daily living and received daily insulin injections as per physician's orders. The insulin pen was observed on the medication tray with an open date but lacked the required resident identification label. Interviews with staff revealed that the insulin pens were typically labeled with the resident's name, but in this instance, the pen was not labeled, and the staff could not explain how it ended up on the cart without proper identification. The Director of Nursing and other staff acknowledged that the pen should have been labeled and that it was not safe to have an unlabeled medication on the cart. Facility policy required medications to be labeled for individual residents and stored separately from floor stock, but this protocol was not followed in this case.