Failure to Label Multi-Dose Insulin Pens with Open Date
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens were labeled with the date and time when first opened for two residents during medication administration. During medication passes, two different LPNs administered insulin using Humalog KwikPens that were not labeled with the date they were first opened, as required by facility policy and manufacturer instructions. One LPN retrieved a new insulin pen, administered the medication, and returned it to the cart without labeling it. When questioned, the LPN stated the pen was the only one open but did not provide a method for other staff to know when it was first used. The other LPN, an agency nurse, administered insulin from an already open pen and was unable to state when it was first opened, incorrectly stating the pen was good for ninety days. Interviews with staff, including a unit manager, confirmed that the expectation is for insulin pens to be labeled with the open and discard dates, and that the pens are only good for twenty-eight days after opening. Facility policies reviewed also require that the date opened be recorded on multi-dose containers and that expiration dates be checked prior to administration. The lack of labeling on the insulin pens created a situation where staff could not verify whether the medication was still within its safe usage period, as required by both facility policy and manufacturer guidelines.